Background: Implant-associated bone infections (IAIs) represent a major clinical challenge, causing implant failure, prolonged morbidity, and costly revision surgeries. Infection risk is highest in the immediate perioperative period, but delayed post-implantation contamination, occurring weeks after surgery in a partially healed host, represents an equally important and underappreciated clinical scenario. Bacteria rapidly colonize implant surfaces and form biofilms that resist both antibiotics and host immune responses, making prevention critical. Well-characterized small-animal models that capture both early and delayed post-implantation infections are therefore essential to develop and test antibacterial implants and coatings. Methods: We developed a rat femoral-segmental-defect model stabilized with a polyether-ether-ketone plate and a 3D-printed porous titanium implant. Three studies were performed using a total of 28 animals (3 excluded due to early humane endpoints; n = 25 in final analysis): (i) early inoculation during surgery with planktonic Staphylococcus aureus (ATCC 49230) at 104 or 106 CFU (colony-forming units) per rat, (ii) delayed inoculation 28 d after surgery with planktonic S. aureus at 104 or 106 CFU per rat, and (iii) delayed inoculation with 108 CFU per rat delivered as planktonic or ruptured-biofilm inoculum. Controls received phosphate-buffered saline at implantation. The primary endpoint was infection at day 14, quantified by CFU enumeration from homogenized bone and from a sonicated implant, plate, and screws. Micro-computed tomography (micro-CT) was used to visualize fixation and hardware position. Results: Early inoculation with 104 or 106 CFU per rat produced consistent infections across bone, implants, and screws. The same doses given 28 d later yielded low and inconsistent colonization. Escalation to 108 CFU per rat in the delayed setting produced consistent infections; the ruptured-biofilm inoculum generated higher implant-associated bacterial burdens than planktonic suspensions, while bone burdens were consistently high in both arms. Conclusions: This femoral-implant rat model demonstrates feasibility for studying both immediate perioperative and delayed post-implantation infections, providing a platform for preclinical evaluation of anti-infection strategies. Timing, inoculum magnitude, and bacterial state critically determine infection establishment.
Three periprosthetic femoral fractures around chronically infected total hip arthroplasties (THAs) were treated according to a pragmatic two-stage treatment framework. Infection control and fracture healing were achieved. This may serve as a reference for surgeons confronted with these complex and technically demanding situations.
Introduction: Periprosthetic joint infection (PJI) is a major cause of failure after total hip arthroplasty (THA) and total knee arthroplasty (TKA). While primary PJI treatment costs are increasingly recognized, the economic burden of septic re-revision surgery remains poorly defined. This study estimated septic re-revisions and the reimbursement burden across Europe. Methods: A payor-perspective health-economic model was applied to 30 European countries, combining 2023 Eurostat arthroplasty data with published infection rates to estimate PJIs and septic re-revisions (including after aseptic revisions), categorized as DAIR (debridement, antibiotics, and implant retention), one-stage, or two-stage procedures. Reimbursement used 13-country survey data plus GDP-based extrapolation; sensitivity analyses varied key parameters by ± 20 %. Results: In 2023, 2.29 million primary arthroplasties were performed in Europe, resulting in an estimated 22 794 PJIs and 8629 septic re-revisions. Total reimbursement costs were estimated at EUR 123.6 million (EUR 74.1 million THA; EUR 49.5 million TKA), split into EUR 111.6 million after primary PJI treatment and EUR 12.0 million after initially aseptic revision. Two-stage exchanges accounted for 82.8 % of expenditures and were the main cost driver; Germany had the highest national costs. A Monte Carlo probabilistic sensitivity analysis yielded a 95 % credibility interval of EUR 102.0-156.2 million. Conclusion: Septic re-revision surgery after arthroplasty represents a substantial economic burden in Europe, largely driven by two-stage exchange procedures. Reducing infection and treatment failure rates may provide major clinical and financial benefits: a 25 % reduction in PJI incidence could save EUR 27.9 million annually (22.6 %), and shifting half of two-stage cases to one-stage a further EUR 22.6 million (18.3 %).
Implant-related biofilm infections remain a major challenge in orthopedic surgery. Prior in vitro comparisons have focused on arthroplasty surfaces using static models; fracture fixation implants remain unstudied. We compared six antiseptic solutions against mature S. aureus biofilms on stainless steel, the most common fracture fixation metal, using a continuous-flow CDC biofilm reactor, more closely approximating hydrodynamic surgical conditions than static systems. Mature biofilms were created on stainless steel coupons using a continuous-flow reactor for 72 h, then washed for 3 min with one of six irrigation solutions: normal saline, 10 % PI (povidone-iodine), 0.35 % PI, a 10 % PI + 3 % hydrogen peroxide mixture, hypochlorous acid, or 0.05 % chlorhexidine gluconate. Colony-forming units (CFUs) were quantified following standardized sonication and plating, and mixed-effects negative binomial regression was used to estimate treatment effects. All antiseptic solutions produced statistically significant reductions in biofilm-associated CFUs relative to untreated controls. Ten percent PI demonstrated the greatest reduction (3.46- log 10 ), with 0.35 % PI producing a similar 3.42- log 10 reduction. The PI-hydrogen peroxide mixture achieved a 3.24- log 10 reduction without evidence of synergistic activity. Hypochlorous acid and chlorhexidine produced 2.95- log 10 and 2.46- log 10 reductions, respectively, while saline demonstrated minimal effect. These findings indicate that PI solutions, even at dilute concentrations, are highly effective at disrupting established biofilms on stainless steel. As an in vitro single-organism model, these findings establish a comparative efficacy baseline on a fracture-fixation-relevant surface but require validation in multispecies, multi-material, and mechanically realistic irrigation systems before clinical translation.
A recent scoping review found no evidence supporting routine ward-level isolation or dedicated septic wards for non-multidrug-resistant organism musculoskeletal infections when standard precautions are applied, whereas targeted measures remain appropriate for multidrug-resistant organisms. An international survey revealed wide variation in attitudes and a persistent belief in supporting evidence, highlighting a gap between evidence and perception and supporting a differentiated, risk-based approach to isolation.
Purpose: Culture-negative periprosthetic joint infection (CN-PJI) poses a significant clinical challenge because antimicrobial selection relies on guesswork rather than robust clinical data. This umbrella review summarizes the prevalence of CN-PJI, diagnostic strategies (including molecular assays), treatment approaches, and outcomes. Methods: We conducted an umbrella review of published systematic reviews and meta-analyses on CN-PJI in adult hip and/or knee arthroplasties. Searches of major bibliographic databases were conducted in December 2025; two reviewers screened studies and extracted data on prevalence, reported risk factors, diagnostic criteria, use of molecular tests, specimen matrix (synovial fluid, periprosthetic tissue, and/or sonication fluid), surgical strategy, antimicrobial selection, and clinical outcomes (infection control or failure). Methodological quality was assessed with AMSTAR 2. Results: Nine reviews were included. Reported CN-PJI prevalence varied widely (11.0 %-63.6 %), reflecting substantial heterogeneity in study populations, diagnostic definitions, microbiological workflows, and pre-analytical factors. Prior antibiotic exposure before sampling was repeatedly identified as an important contributor to culture negativity. Molecular diagnostics, predominantly NGS (next-generation sequencing)-based approaches, were evaluated in five out of nine reviews, with highly variable organism detection rates depending on assay type, specimen source, and study context. Where meta-analytic estimates were available, pooled sensitivity ranged from 0.81 to 0.93, and pooled specificity ranged from 0.92 to 0.97. Treatment strategies and outcome definitions were inconsistently reported across reviews; when extractable, two-stage exchange was the most frequently described surgical strategy. Conclusions: CN-PJI remains common and variable across settings. Molecular diagnostics improve pathogen detection but do not eliminate false negatives. Reported failure rates varied across reviews and appeared to be clinically relevant, although differences in outcome definitions, treatment protocols, and follow-up duration limited direct comparison.
Introduction: Recent work in total knee arthroplasty (TKA) prosthetic joint infection (PJI) suggests that timing from hospital admission to DAIR (debridement, antibiotic, and implant retention) is a modifiable risk factor influencing treatment outcomes. The study assessed the impact of timing from admission to DAIR on clinical outcomes and treatment success in the total hip arthroplasty (THA) PJI population. Methods: A retrospective review was conducted at a specialized PJI tertiary referral centre. Patients who underwent DAIR for THA PJI between 2008 and 2021 with a minimum 2-year follow-up were included. The primary outcome was reoperation for recalcitrant PJI. Secondary outcomes included 90 d readmission, 90 d and 1-year mortality, and postoperative complications. Multivariate regression analysis identified factors associated with DAIR outcomes. Results: A total of 100 patients satisfied the inclusion criteria. The mean time from admission to DAIR was 46.4 ± 45.1 h, and 52.0 % required reoperation for recalcitrant PJI. Prolonged time from admission to DAIR was associated with increased 90 d mortality (odds ratio or OR: 1.02, CI (confidence interval) 95 %: 1.00-1.03, p = 0.04). Increasing age was associated with greater 1-year mortality (OR: 1.06, CI 95 %: 1.00-1.12, p = 0.049). McPherson host grade C compared to grade A was associated with both greater 1-year mortality (OR: 12.75, CI 95 %: 1.11-146.09, p = 0.04) and postoperative complications (OR: 7.59, CI 95 %: 1.22-47.08, p = 0.03). McPherson extremity grade II versus grade I (OR: 3.28, CI 95 %: 1.21-8.92, p = 0.02) and revision THAs (OR: 0.15, CI 95 %: 0.03-0.72, p = 0.02) were associated with postoperative complications. Lower haemoglobin levels (OR: 1.04, CI 95 %: 1.01-1.07, p = 0.004) were associated with higher reoperation risk. Conclusion: In a DAIR-treated cohort, increased time from admission to surgery was associated with greater 90 d mortality in THA PJI patients. Timely surgical intervention and optimization of modifiable risk factors are essential to improve outcomes.
Introduction: Periprosthetic joint infection (PJI) remains a major complication of joint arthroplasty, requiring rapid and accurate pathogen identification to guide appropriate antimicrobial therapy. Conventional culture is limited by prolonged turnaround times and reduced sensitivity, particularly following antibiotic exposure. This study evaluated the diagnostic performance and clinical relevance of Molecular Culture® (MC), a rapid PCR-based assay, using sonication fluid (SF) obtained during revision arthroplasty. Methods: SF samples from patients undergoing hip or knee revision arthroplasty (2019-2023) were retrospectively analysed. Patients were classified as PJI or non-PJI according to European Bone and Joint Infection Society criteria. MC results were compared with conventional SF culture. Positive percentage agreement (PPA) and negative percentage agreement (NPA) were calculated using culture as the reference standard. Clinical agreement was assessed using all available microbiological results and relevant clinical information, including recent antibiotic exposure. Results: A total of 203 SF samples from 172 patients were included. Analytical PPA and NPA of MC were 68.1 % (95 % CI, 59.9-75.3) and 84.6 % (95 % CI, 73.9-91.4), respectively. Following clinical correlation, PPA and NPA at patient level were 73.2 % (95 % CI, 64.9-80.2) and 95.6 % (95 % CI, 85.2-98.8), respectively. MC identified 11 additional clinically relevant pathogens and provided results within approximately 4 h. Conclusions: MC demonstrated high clinically adjusted agreement and faster turnaround times than conventional culture, supporting its role as an adjunctive diagnostic tool for PJI. Its value may be greatest in patients with uncertain infection status or prior antimicrobial exposure, where rapid exclusion of infection could facilitate earlier optimisation of antimicrobial therapy.
Background: Prosthetic joint infection (PJI) complicates 0.5 %-2.0 % of total joint arthroplasties and remains the leading cause of implant failure. Bacterial biofilm confers marked antimicrobial resistance, and current strategies, including debridement, antibiotics, and implant retention (DAIR), carry a pooled failure rate of ∼ 36 %. Novel biofilm-disrupting adjuncts are urgently needed. Purpose: The aim is to examine preclinical evidence of bromelain and N-acetylcysteine (BromAc) as a combination antibiofilm therapy in PJI management and to critically appraise its translational readiness. Methods: A narrative literature search was conducted for studies examining N-acetylcysteine, bromelain, and BromAc in the context of biofilm disruption on orthopaedic prosthetic materials. Eligible studies were appraised qualitatively for pathogen, substrate, exposure conditions, outcome measures, and methodological limitations to allow comparative interpretation rather than narrative summary alone. Results: N-acetylcysteine demonstrates concentration-dependent antibiofilm activity, achieving approximately 50 % biofilm reduction on polyethylene and 20 % on titanium at minimum inhibitory concentrations, rising to 81.5 % eradication of staphylococcal biofilms at higher concentrations in non-orthopaedic substrates. Bromelain achieves significant biofilm reduction from orthopaedic hardware via proteolytic degradation of extracellular polymeric substance protein scaffolds. In the principal proof-of-concept study on hernia mesh, BromAc achieved > 80 % biofilm removal (quantified by crystal violet biomass reduction) across three Pseudomonas aeruginosa strains, exceeding either agent alone; activity against staphylococci has been reported in unpublished sponsor data but is not yet independently replicated in peer-reviewed orthopaedic models. Conclusions: BromAc represents a mechanistically rational adjunctive therapy for PJI, targeting distinct biofilm matrix components. However, current evidence is largely preclinical, much of it derived from non-orthopaedic substrates and pathogens, and several supporting datasets are unpublished sponsor data. Important translational gaps remain in peer-reviewed staphylococcal validation on prosthetic materials, formulation stability (particularly the susceptibility of N-acetylcysteine to oxidation in aqueous solution), intra-articular safety with respect to cartilage and osseointegration, and the absence of an in vivo orthopaedic implant model. These limitations must be resolved before clinical translation can be responsibly considered.
Background: Sonication fluid culture (SFC) of osteosynthesis material may be a valuable adjunct tool to diagnose fracture-related infection (FRI). This study aims to evaluate the added diagnostic value of SFC as a diagnostic tool. The diagnostic value of SFC was assessed by evaluating its impact on confirming microbiological results and changing diagnosis. Methods: We analysed patients undergoing osteosynthesis hardware removal between 2012 and 2021. We categorized patients using FRI consensus criteria: suspected FRI or confirmed FRI. The sensitivity and specificity of tissue cultures and SFC were assessed. The added value of SFC was determined as the number of cases where SFC was essential for confirming FRI and the influence on antibiotic therapy selection. Results: We included 96 patients with three or more tissue cultures. Based on diagnosis without SFC, we found 14 aseptic, 35 suggestive FRI cases, and 47 confirmed FRI cases. Following SFC results, four cases changed diagnosis from aseptic to suggestive FRI, and three cases changed from suggestive FRI to confirmed FRI. The sensitivity of tissue culture was 74 %, and the specificity was 98 %. The sensitivity of SFC was 84 %, and the specificity was 83 %. Combining tissue cultures with SFC significantly increased sensitivity compared with tissue cultures alone, from 74 % to 88 % ( p < 0.001 ). In 21 confirmed FRIs (42 %), SFC results were concordant with tissue cultures and would not alter FRI management. SFC detected an additional virulent pathogen in three confirmed FRIs (6 %) and low-virulent pathogens in eight confirmed FRIs (16 %) which could influence the antibiotic regimen. Conclusions: SFC plays a significant role in diagnosing FRI by enhancing pathogen detection. SFC may influence FRI management in approximately 6 % to 16 % of confirmed FRI. In every FRI, an adequate number of cultures according to protocol should be obtained, and SFC should also be performed.
Introduction: Culture-negative periprosthetic joint infection (CN-PJI) remains a major diagnostic and therapeutic challenge because antimicrobial and surgical management are often empirical. Methods: We performed a systematic review and meta-analysis to evaluate treatment strategies and outcomes of CN-PJI. MEDLINE and Scopus were searched through 3 July 2025, and 27 cohort studies including 1399 CN-PJI patients were included. Results: Random-effect meta-analyses showed a pooled treatment success proportion of 83.6 % (95 % CI, 78.2-87.9), a pooled failure proportion of 17.2 % (95 % CI, 12.6-22.9), and a pooled mortality proportion of 2.4 % (95 % CI, 1.3-4.6). Subgroup analyses demonstrated lower success and higher failure with debridement, antibiotics, and implant retention compared with one-stage and two-stage exchange arthroplasty. Hip CN-PJI showed higher reported success than knee CN-PJI. Antimicrobial regimens were highly heterogeneous and were not suitable for pooled analysis. Conclusion: Overall, CN-PJI may have favorable outcomes, particularly with exchange arthroplasty, but prospective studies with standardized definitions and treatment reporting are needed.
Background: Fracture-related infection (FRI) represents one of the most challenging complications in trauma care and disproportionately affects patients in low-resource settings, where diagnostic capacity, surgical infrastructure, and access to microbiology and reconstructive expertise are limited. Methods: An expert group was convened through the African Bone and Joint Infection Network (ABJIN) under the auspices of the European Bone and Joint Infection Society (EBJIS) and with support from the AO Alliance. Recommendations were developed through a three-step process: (1) a two-part survey assessing current practice and priority needs among clinicians from African countries, (2) an in-person multidisciplinary consensus meeting during the COSECSA Congress (Harare, 2024), and (3) an iterative collaborative review by a wider panel of clinicians from 14 countries. Results: The group produced context-adapted recommendations covering prevention, terminology, diagnosis, investigations, holistic patient optimization, antimicrobial therapy, local antibiotic delivery, and surgical management of FRI in low-resource settings. Key themes include the following: management of open fractures; diagnostic pathways prioritizing clinical criteria and intra-operative sampling; antimicrobial strategies reflecting local microbiology and drug availability; affordable local antibiotic carriers; and the importance of soft-tissue management, multidisciplinary collaboration, and centralization of complex cases. Barriers specific to low-resource settings - delayed presentation, restricted microbiology services, limited implant availability, and high burdens of comorbidities - were integrated into the recommendations. Conclusion: These consensus-based, context-specific recommendations provide practical guidance for FRI in low-resource settings. They aim to support clinicians in delivering safe, cost-effective care, accepting structural limitations while promoting standardization and audit. Further clinical research from low- and middle-income countries is needed to strengthen the evidence base and refine these recommendations.
Bone and joint infections secondary to Candida species are associated with high morbidity and mortality, requiring extended courses of antifungal therapy, with parenteral medications being first-line therapy. The reported use of antifungals in outpatient parenteral antimicrobial therapy (OPAT) for deep-seated bone and joint infections is limited. We report and discuss the use of rezafungin, a novel long-acting echinocandin, in an OPAT setting for spondylodiscitis secondary to Candida albicans.
Background: Periprosthetic joint infection (PJI) remains a devastating complication after hemiarthroplasty in elderly patients with femoral neck fractures. Early identification of high-risk patients is important. The systemic immune-inflammation index (SII), calculated as platelet × neutrophil / lymphocyte count, is a marker of systemic inflammation, although its role in this population remains unclear. Methods: This retrospective single-centre study included patients aged ≥ 65 years who underwent hemiarthroplasty between 2015 and 2025. Preoperative and postoperative day-5 SII values were calculated from routine blood tests. Δ SII was defined as the difference between postoperative and preoperative values. The primary outcome was PJI within 1 year after surgery. Logistic regression and receiver operating characteristic (ROC) analyses were performed. Results: A total of 976 patients were included, of whom 47 (4.8 %) developed PJI. Postoperative SII values were significantly higher in patients with PJI, whereas preoperative SII was not associated with infection risk. In multivariable analysis, postoperative SII remained independently associated with PJI (OR 1.195, 95 % CI 1.144-1.248, p < 0.001 ). Δ SII was also independently associated with PJI (OR 1.124, 95 % CI 1.085-1.164, p < 0.001 ). ROC analysis demonstrated good discriminatory performance for postoperative SII (AUC 0.882), with an optimal cut-off value of 2118. In contrast, Δ SII showed moderate discriminatory performance (AUC 0.764), with an optimal cut-off value of 656. Conclusions: Postoperative SII and Δ SII were independently associated with PJI after hemiarthroplasty. SII may aid early postoperative risk stratification and clinical decision-making when interpreted alongside clinical findings.
Native vertebral osteomyelitis (NVO) remains a diagnostic challenge due to its non-specific presentation and the limited sensitivity of culture-based methods. Blood cultures and image-guided biopsies are considered the diagnostic standards, but their yield is often low, especially in patients who have received prior antibiotics or are infected with fastidious microorganisms. Recent molecular techniques, including polymerase chain reaction (PCR) and next-generation sequencing (NGS), have improved pathogen detection and enabled more targeted antimicrobial therapy. In this narrative review, we summarize the diagnostic methods used in NVO, including conventional microbiological and molecular approaches, and present their strengths and limitations based on previous studies. We particularly focus on situations where molecular diagnostic techniques, such as 16S rRNA PCR, NGS, and microbial cell-free DNA testing, outperform traditional culture-based methods in sensitivity, while their specificity may be comparatively lower. Combining these molecular tools with standard diagnostic procedures may improve pathogen detection, guide targeted treatment, and enhance diagnostic accuracy in culture-negative or antibiotic-pretreated cases. Understanding the advantages and limitations of each diagnostic method can help clinicians to choose the most appropriate testing strategy, reduce diagnostic delays, and improve patient management in suspected NVO.
Background: Periprosthetic joint infection (PJI) is a devastating complication of arthroplasty and is difficult to diagnose accurately. This study aims to explore the value of neutrophil extracellular traps in synovial fluid (SF-NETs, web-like structures released by neutrophils as a critical innate immune response) for diagnosing PJI. Methods: A retrospective cohort study was conducted, enrolling post-arthroplasty subjects from January 2018 to December 2023. Three components of SF-NETs (cell-free double-strand DNA, SF-dsDNA; citrullinated histone H3, SF-CitH3; SF-Nucleosome) and SF-NETs1+ (positive with one out of the three NET components), SF-NETs2+ (positive with two out of the three NET components), white blood cell count (SF-WBC), polymorphonuclear cell percentage (SF-PMN %), neutrophil count in SF (SF-PMN), microbiological examinations (Culture) and infection-related systemic indices were evaluated. Results: A total of 64 of 153 included subjects were diagnosed as PJI. SF-dsDNA and SF-CitH3 had significantly higher levels in the PJI group compared to the non-PJI group ( P < 0.001) and showed positive correlations with SF-WBC, SF-PMN % and SF-PMN (0.4 < ρ < 0.7), while SF-Nucleosome had no significant difference. Sensitivity and specificity of SF-NETs1+, SF-NETs2+ and Culture were 82.2 % and 78.7 %, 59.4 % and 95.5 %, and 54.1 % and 86.8 %, respectively. The NET related index (NETRI) was defined as 10.529 × SF-NETs 1 + + 28.114 × SF-PMN % + 8.210 × Culture-1.452, with the area under the receiver operating characteristic curve of 0.922, making it a novel indicator. Conclusions: SF-NETs1+ and SF-NETs2+ may serve respectively in the screening and exclusion of PJI. NETRI represented a new discriminator for PJI diagnosis.
Background: Gram-negative (GN) bacteria are an increasingly recognized cause of prosthetic joint infection (PJI), accounting for 10 %-20 % of cases. However, epidemiological data from European centres remain limited. This study aimed to evaluate the incidence, risk factors, microbiological profile, and treatment outcomes of GN PJI in several European tertiary referral hospitals. Methods: We conducted a retrospective multicentre study including all culture-positive hip and knee PJIs diagnosed between 2014 and 2018 at three tertiary hospitals in Italy, Spain, and Switzerland. Demographic characteristics, comorbidities, surgical management, microbiological data including antimicrobial susceptibility, and treatment outcomes were analysed. Treatment success was defined as absence of persistent or recurrent infection requiring additional surgery, prosthesis removal, infection-related mortality, or long-term suppressive antibiotic therapy. Results: Among 780 confirmed PJIs, 71 (9.1 %) were caused by GN bacteria. The most frequent pathogens were polymicrobial infections (29.6 %), Escherichia coli (25.4 %), and Pseudomonas aeruginosa (19.7 %). GN PJI mainly affected elderly patients (median age 74 years), females (60.6 %), and those with comorbidities such as diabetes mellitus (32.4 %) and those who are overweight/obese (62 %). Hip infections were more common than knee infections (59.2 % vs. 40.8 %). Overall treatment success was 89 %. Two-stage revision showed the highest success rate of 94.8 % compared with one-stage exchange (88 %) and DAIR (81 %). Ciprofloxacin was used in 72 % of cases. Conclusions: GN PJI incidence was comparable to that of previous reports. These infections occur more often in elderly patients with comorbidities. Two-stage revision remains the most effective surgical strategy, and ciprofloxacin continues to be a key component of antimicrobial therapy for susceptible GN infections.
Topical intrawound vancomycin powder has been widely adopted in orthopaedic surgery as an adjunct for the prevention of surgical site infection (SSI) and periprosthetic joint infection (PJI). Retrospective cohorts and derived meta-analyses have long suggested a consistent benefit, and the technique became established practice at many institutions. Over the past 5 years, prospective randomised evidence has added an important corrective to this picture. The VPIP trial (Saba et al., 2025) randomised 1901 high-risk patients undergoing primary hip or knee arthroplasty across 17 US centres and found no benefit of vancomycin, dilute povidone-iodine, or their combination over saline for any 3-month infection endpoint; a biostatistical projection to 80 000 patients left the number needed to treat near 500, and enrolment was closed for statistical futility. The VANCO trial in high-risk tibial fractures (O'Toole et al., 2021) narrowly missed its primary endpoint ( P = 0.06 ) but demonstrated a significant post hoc reduction in gram-positive deep infections without gram-negative shift. Mechanistic data indicate that sub-inhibitory vancomycin concentrations increase Staphylococcus aureus biofilm formation and raise infection rates in vivo - an effect not reproduced by cefazolin. Current international guidance does not issue a general recommendation for topical vancomycin, a position consistent with this more differentiated evidence base. The present review integrates these strands into an indication-specific framework that separates prophylactic application in clean surgical fields, where benefit is now in serious doubt, from adjunctive-therapeutic application in established infection, and identifies the settings in which topical vancomycin may still be considered individually and those in which it should be avoided.
Background: Optimal outcomes in periprosthetic joint infection (PJI) and other complex orthopaedic infections depend on longitudinal, multidisciplinary input from infectious disease (ID) specialists. Much of this work is not directly billable, and the financial structures that support it have not been systematically described in any healthcare system. Methods: We distributed an anonymous online cross-sectional survey to ID physician members of the Musculoskeletal Infection Society (MSIS) and the Infectious Diseases Society of America Bone and Joint Interest (IDSA-BOJO) group between 12 December 2025 and 30 January 2026. The survey captured practice setting, clinical and non-clinical orthopaedic ID responsibilities, and sources of compensation and protected time. Data were analysed descriptively; no inferential statistical testing was performed. Results: Fifty-two ID physicians responded, 94 % from US academic medical centres. Median ID clinical effort was 70 % (IQR 60 %-81 %); of this, a median of 55 % (IQR 40 %-90 %) was devoted to orthopaedic infections. Compensation was most commonly a base salary plus productivity incentives (53 %) or base salary alone (40 %) and was funded by medicine/ID in 88 % of cases. Care coordination (90 %), curbside consultation (85 %), trainee education (77 %), and guideline development (71 %) were performed; 83 % of respondents received no protected time or dedicated funding for any of these non-billable activities. Conclusions: In this descriptive, hypothesis-generating national survey of highly subspecialized US ID physicians, compensation structures were dominated by clinical productivity and rarely included protected time for the non-billable coordination work that underpins modern multidisciplinary PJI care. These findings should be interpreted in the context of a small, academic-predominant sample and of substantial international variation in healthcare financing, and they support the need for larger international studies of how orthopaedic ID expertise is funded and protected.
Background: Total joint arthroplasty (TJA) is an increasingly common intervention in the US, with an expected proportionate rise in periprosthetic joint infection (PJI). As part of the treatment plan, long-term suppressive oral antibiotic therapy is sometimes used in patients who would not benefit from further surgical intervention of their PJI. The aim of this scoping review is to outline the current evidence surrounding PJI incidence in new primary arthroplasty in this patient population. Methods: A search was conducted using the PubMed and Scopus databases with no date restrictions. Studies examining the incidence of developing a PJI after new primary hip or knee arthroplasty in patients receiving chronic suppressive antibiotic therapy for a prior PJI were included. Two authors independently screened the results for inclusion in this review. Results: Three retrospective cohort studies were ultimately included. Across studies, 61 patients with prior PJI receiving chronic suppressive antibiotics undergoing new primary TJA were identified. PJI rates in suppressed patients ranged from 0 % to 21.4 % compared to 0 % to 2.9 % in non-suppressed patients with prior PJI and 0 % to 2.6 % in matched controls without prior PJI. Conclusion: Limited evidence exists regarding PJI risk in new primary arthroplasty among patients on chronic suppression for prior PJI, with a wide range of incidence reported across studies. Due to a lack of direct evidence examining this specific patient population, further research must be conducted in order to support strong recommendations.
