Prosthetic joint infection (PJI) following arthroplasty is associated with high morbidity and financial cost. Patients often undergo multiple complex procedures, prolonged inpatient stays and outpatient parenteral antibiotic therapy (OPAT). We aim to quantify the economic implications of the inpatient and OPAT costs of the management of private patients treated in the public healthcare system. Retrospective analysis of operative PJI cases between September 2020 and September 2025 was performed. Included patients were those who had primary total hip replacement (THR) or total knee replacement (TKR) for osteoarthritis or trauma. Data included inpatient stay, OPAT utilization, surgical procedures (debridement, antibiotics, and implant retention (DAIR); and revisions), and private/public status at index procedure. Costs were estimated using available Health Service Executive (HSE) information on operative costs and bed days. There were 40 operative PJI cases in our centre over the study period. There were 22 TKRs and 18 THRs. Eighteen had their initial surgery publicly, whereas 14 had their initial surgery privately. A total of 19 patients underwent DAIR while the rest underwent one or several revisions. Combined total length of stay was 1796 bed days. The operative PJI burden over that period was EUR 5 005 339 (median EUR 84 232 per episode) or approximately EUR 1 000 000 yr−1. Fourteen private patients treated in our centre had publicly funded treatment at an estimated cost of EUR 1 967 270 over a 5-year period or EUR 393 454 yr−1. Operative PJI imposes a substantial clinical and financial burden. Private patients treated in public hospitals contribute to the total costs, raising the justification for private healthcare contributions to publicly treated complications arising after private procedures.
Late fracture-related infection (FRI) after intramedullary nailing may extend beyond the fracture site to involve the medullary canal, nail entry site, and locking screw tracts. This retrospective cohort study evaluated a staged protocol incorporating systematic multi-regional debridement of the entire nail-related infection pathway. We reviewed 47 patients treated between January 2017 and January 2025, all of whom had fracture nonunion and an interval of at least 3 months from the first documented confirmation of FRI to admission. Stage I included intramedullary nail removal; systematic multi-regional debridement of the fracture/nonunion site, nail entry site, entire medullary canal, and proximal and distal locking screw tracts; locking plate fixation; and temporary vancomycin-loaded polymethyl methacrylate cement placement for dead-space management and induced membrane formation. Definitive Stage II reconstruction included the removal of the temporary plate construct and cement, repeat debridement, bone grafting, and definitive fixation with a new internal locking plate after clinical and laboratory infection quiescence and intraoperative reassessment. The cohort included 21 tibial and 26 femoral cases, with a mean follow-up of 25.3 ± 14.1 months. Two patients had confirmed persistent infection requiring repeat debridement before definitive Stage II reconstruction. No confirmed recurrence or unplanned surgical debridement for suspected recurrence occurred after definitive reconstruction. Union after the index Stage II reconstruction was achieved in 44 of 47 patients (93.6 %). The remaining three patients achieved union after further surgery, resulting in a final union rate of 100 %. The mean times to radiographic union and full weight-bearing were 9.7 ± 2.1 and 11.3 ± 3.8 months, respectively. Median (interquartile range) WBC count, ESR, and CRP decreased from 7.2 (6.2–9.0) × 109 L−1, 39.0 (12.5–65.0) mm h−1, and 26.5 (10.3–43.2) mg L−1 to 5.9 (5.0–7.7) × 109 L−1, 17.0 (8.0–29.5) mm h−1, and 6.3 (3.7–8.9) mg L−1, respectively. LEFS and SF-36 scores increased from 47.0 (37.0–65.5) and 417.0 (335.0–439.0) to 70.0 (61.0–75.5) and 491.0 (480.0–516.5), whereas VAS and SAS scores decreased from 4.0 (4.0–4.0) and 45.0 (42.0–50.0) to 1.0 (0.0–1.0) and 32.0 (29.5–37.0), respectively (all p≤0.001). These findings support the feasibility of this staged protocol in selected patients with late post-intramedullary-nailing FRI and nonunion.
Current periprosthetic joint infection (PJI) definitions classify sinus tracts as present or absent. While this binary approach is appropriate for diagnosing PJI, it does not capture the heterogeneity of sinus tracts relevant to surgical decision-making. We propose that future studies explore a standardized characterization of sinus tract complexity to better inform surgical treatment.
Background: The co-occurrence of periprosthetic fractures and infection, referred to as infected periprosthetic fracture (iPPF), represents a highly burdensome complication in orthopedic surgery. Management is challenging since not rarely treatment principles of prosthetic joint infections and fracture-related infections have to be combined. The aim of this scoping review was to map the current literature on management and outcome of iPPFs. Methods: A scoping review was conducted in accordance with PRISMA-ScR guidelines. Five major databases were systematically searched. Studies reporting on diagnostic principles and/or treatment strategies for iPPF around the hip and knee were included. Data were mapped regarding study design, diagnostic approaches, surgical strategies, and outcome. Results: A total of 32 studies comprising 273 patients with iPPFs were included; 8 addressed diagnostic strategies, and 24 reported on treatment and outcome. Diagnostic studies demonstrated limited reliability of serum inflammatory markers, and although synovial fluid analysis appeared most informative, optimal thresholds remain uncertain. Most treatment studies were small and heterogeneous. A staged surgical approach, predominantly two-stage revision, was reported in 83 % of the included studies. Across nine studies reporting outcomes, mean infection eradication and recurrence rates were 76.1 % and 22.3 %, respectively. The majority of the studies (58.3 %) described that additional surgeries were needed to cure infection. Fracture healing outcomes were inconsistently reported (bone healing in 4 out of 9 studies with 53/58 fractures, mean 91.4 %). Conclusion: This scoping review demonstrates that management of iPPFs remains highly challenging, with high rates of recurrent infection and unplanned revision surgery. However, the reported quantitative outcome data represent descriptive summaries derived from heterogeneous, predominantly small observational studies and case series and should not be interpreted as definitive benchmarks for clinical outcomes. The current evidence base remains limited, highlighting the need for standardized diagnostic criteria, uniform outcome reporting, and well-designed prospective multicenter studies.
Background: Diabetic-foot osteomyelitis (DFO) is a severe complication of diabetic-foot ulcers associated with delayed healing, amputation, and increased mortality. Machine learning (ML) has increasingly been explored for diagnosis and clinical decision-making in diabetic-foot care; however, the current evidence specific to DFO has not been systematically synthesized. Methods: We performed systematic searches of MEDLINE, Embase, Scopus, and Web of Science for studies published between January 2000 and May 2026. Studies that developed or evaluated ML models for DFO diagnosis, prediction, or outcomes were included. Data extraction was performed using the CHARMS framework, reporting followed PRISMA 2020 and TRIPOD-SRMA recommendations, and methodological quality was evaluated using PROBAST + AI. Due to considerable heterogeneity, narrative synthesis was performed. Results: A total of 10 studies published from 2022 to 2026 met the inclusion criteria. Five studies developed or evaluated ML models with a direct DFO diagnostic endpoint, one additional study evaluated model explainability, and four evaluated complementary DFO-relevant diabetic-foot applications. Reported discrimination ranged from 0.879 to 0.998, but comparisons were limited by differences in clinical endpoints, reference standards, input modalities and validation strategies. Only one direct DFO model was externally validated, and no study developed a multimodal model combining clinical and imaging data. Conclusion: Current evidence is limited by heterogeneous methodologies, limited external validation, and inconsistent reporting despite promising discrimination reported by several models. Future studies should evaluate whether multimodal models integrating clinical and imaging data provide incremental value over unimodal approaches, with external validation, calibration, and clinical utility assessment before clinical implementation.
