Background/Objectives: Posttraumatic infections are common in emergency hand surgery. Amputation is the worst outcome and can occur at admission or during the course of antibiotic treatment and iterative surgical debridement. We wondered if the prolongation of antibiotic treatment beyond the usual indication, and more surgical debridement besides its immediate benefit, could reveal additional preventive effect against amputation during or immediately after therapy. Methods: We investigate 166 risk association (variables) of community-acquired (traumatic) hand infection with overall treatment failure using a specifically designed retrospective single-center cohort between 1 November 2018 and 31 October 2020. Results: Among 600 patients (362 males; 71 (11.8%) with diabetes mellitus), 58 (9.7%) required initially unplanned amputation during the therapeutic ourse. Multivariate Cox regression analysis identified only inherent risks associated with "amputation": male sex (hazard ratio [HR] 3.12, 95% confidence interval [CI] 1.28-7.69, p = 0.01), age (HR 1.03, 95% CI 1.01-1.04, p = 0.03), diabetes (HR 2.40, 95% CI 1.15-5.01, p = 0.02), whereas no interventional variables such as early flapping or antibiotic-related parameters (early empirical antibiotic use, total duration of antibiotics including its initial parenteral use, and choice of agent) altered outcomes. Conclusions: In severe (traumatic) hand infections among 600 patients, the outcomes were determined by the extent of trauma and underlying comorbidities. The outcomes do not seem to be effectively reduced by more surgery or initial antibiotic treatment.

Background/Objectives: When presented with chronic osteomyelitis of the diabetic foot (DFO), clinicians, patients and their families have two options: rational use of antibiotics or direct surgery. Methods: We conducted a narrative, scientific literature review and administered questionnaires to DFO experts to investigate the factors indicating conservative, antibiotic-based therapy vs. direct surgery to treat DFO. Results: If large necrotic areas and destructed bone are present, providers may opt for a direct surgical amputation or internal resection of the infected bone (conservative surgery). Alternatively, they can choose conservative (targeted) antibiotic therapy lasting several weeks, with minimal soft tissue debridement, off-loading and iterative professional wound care. Conclusions: It is difficult to decide between the two treatments. The rationale for choosing either approach is complex, involving many clinical aspects to consider, which we discuss in this article.

Background/Objectives: When presented with chronic osteomyelitis of the adult diabetic foot (DFO), clinicians, patients and their families have two options: rational use of antibiotics or direct surgery. Methods: We conducted a scientific literature review of 118 different articles and administered questionnaires to eighty DFO international and Swiss experts who have already published on the specific choice between a first-line conservative, antibiotic-based therapy versus direct surgery for DFO. Results: According to this specific literature and the ranking of clinical importance, the presence of ischemia came first (91% consensus favoring surgery), followed by the presence of gangrene (94% consensus), the perceived frailty of the patient (80%), sepsis (83%), and major soft tissue loss (81% consensus). Generally, for more than 90% of all experts, gangrene, bone exposed to air, destroyed bone, and hindfoot DFO motivated for direct surgery. We obtained twenty-four questionnaires from colleagues who we addressed as experts. Their opinions aligned with the literature. Compared to the international experts, Swiss clinicians were less hesitant to amputate in case of long-lasting foot ulcers, soft tissue loss, sepsis or patients with a history of low compliance. Combining literature reviews and questionnaires, large necrotic areas and destructed bone may predict direct surgery. Alternatively, clinicians can choose a first-line antibiotic therapy with minimal soft tissue debridement, off-loading and professional wound care. Conclusions: There is no universal consensus. The decision between antibiotics and surgery remains individualized, while severe ischemia, destroyed bone and large tissue loss are predictors of direct surgery; their absence favors antibiotic treatment.

The Wound Healing Foundation (WHF) previously organized consensus panels on the management of chronic wounds (2022), acute wounds (2024), and diabetic wounds (2025). This WHF consensus statement, authored by a global interdisciplinary panel of clinicians and researchers, focuses on the management of infected wounds. The panel members reviewed the literature and reached consensus on elements of an evidence-based approach to infected wounds. Using a structured format, this statement progresses from discussing how wound infections develop, how to diagnose them, how to provide the most appropriate antimicrobial and surgical treatment, how to assess response to treatment, and how to further investigate instances of unsuccessful treatment.

Background/Objectives: The optimal duration of postoperative antibiotic therapy for bone and orthopaedic implant infections remains undefined. The SALATIO Trials are prospective randomised trials investigating whether shorter antibiotic courses are non-inferior to standard durations across different infection strata. This report presents the second interim analysis. Methods: Two unblinded non-inferiority RCTs were conducted (intention-to-treat population). Primary outcomes were remission, clinical failure, and microbiologically identical recurrence. In SALATIO 1 (material arm), participants with infected implants, retained or replaced during initial surgery, were randomised to short-course (six weeks) or long-course (twelve weeks) targeted systemic antibiotic therapy following debridement. In SALATIO 2 (non-material arm), participants undergoing implant removal or two-stage exchange were randomised to either a short-course (three weeks) or a long-course (six weeks) of antibiotic therapy. Results: We analysed 175 infections with a minimum follow-up period of one-year from October 2022 until July 2025: 69 (39%) in the material arm (38 short-course [55%], 31 long-course [45%]) and 106 (61%) in the non-material arm (44 short-course [42%], 62 long-course [58%]). No significant differences in clinical failure (19% overall) or microbiological recurrence (7%) were observed between treatment arms in either stratum. Multivariate analysis identified diabetes mellitus and number of debridements-but not antibiotic duration-as independent risk factors for clinical failure. Patients receiving short-course therapy experienced significantly fewer adverse events (median 0 versus 1; p = 0.01). Formal non-inferiority has not yet been achieved due to limited statistical power; the current analysis includes 175 of the 280 episodes (62.5%) required for the final analysis. Conclusions: This interim analysis suggests no disadvantage of shorter antibiotic regimens in surgically treated orthopaedic infections, whilst reducing adverse events. Patient comorbidities and surgical factors appear to be more relevant to treatment outcomes than antibiotic duration. The SALATIO Trials are ongoing and may support improved antibiotic stewardship without compromising outcomes. Trials Registration: NCT05499481.

Background : Few randomized studies address the efficacy of negative pressure wound therapy (NPWT) for acute, non-infected orthopedic wounds and diabetic foot ulcers in orthopedic patients. We perform a randomized-controlled trial (RCT) to evaluate if NPWT using the PICO system (PICO 7 Set, donated by Smith & Nephew) achieves a superior and/or a more rapid wound closure rate compared to standard professional wound debridement alone. Methods : We perform an unblinded, single-center RCT in adult orthopedic patients (superiority margin of 15%, power of 80%) with the primary outcome "wound closure without surgical revision" within 42 days. Success of closure is defined as a reduction of wound size by at least 90%. Secondary outcomes are the rapidity of this closure, potential adverse events of treatment, length of hospital stay, and overall costs. The RCT allocates uninfected wounds 1:1 between PICO therapy (1-6 weeks with weekly change of devices) and standard wound care (professional debridement alone for 1-6 weeks); stratified for diabetic foot ulcers and postoperative dehiscence. We need 2 x 150 wound episodes with a minimal follow-up of 42 days. The study will last two years with an interim analysis after one year. Discussion : The BALPIC Trial will provide evidence-based guidance on PICO use for acute wound complications in orthopedic patients, potentially reducing the need for surgical revision, reducing the length of hospital stay and costs and improving outcomes. Trial registration : ClinicalTrial.gov NCT07398534. Registered on 10 February 2026. Protocol version : 3 (20 January 2026)

Background/Objectives: In orthopedic (diabetic) foot surgery, the serum C-reactive protein (CRP) level is frequently measured not only as a diagnostic tool, but also as a control inflammatory marker in the follow-up of postoperative surgical-site infections (SSIs) Methods: We investigated the predictive value of the post-debridement routine (control) serum CRP level in adult (diabetic) patients with an SSI in the foot. We excluded community-acquired (diabetic foot) infections and focused on the predictive accuracy of routine (control) CRP measurements in terms of ultimate therapeutic failures. Results: The median pre- and postoperative CRP levels were 25 mg/L and 8.8 mg/L, respectively. In group comparisons and multivariate assessment, neither the immediate (relative and absolute) drop in the serum CRP level, nor its values between 5 and 8 weeks and between 11 and 14 weeks predicted the failure risk of 19%. In contrast, in cases of surprisingly elevated CRP levels, this finding leads to unnecessary radiological (median costs approximatively USD 200), clinical, microbiological urinary sample (median costs USD 50), and laboratory (one CRP sample USD 10) exams. These additional exams also likely prolong the duration of hospitalization by one to two days (e.g., whilst awaiting the microbiological results) and often generate unnecessary consultations among internist and/or infectious diseases experts (USD 50). Conclusions: Routine, postoperative CRP monitoring during the treatment of established orthopedic (diabetic) foot SSIs is unnecessarily costly, and should be avoided in favor of clinical surveillance of the postoperative evolution.

Background/Objectives: In staphylococcal implant infections, there is often discussion about the optimal postoperative timing of the introduction of rifampicin in the postoperative period with open wounds. Methods: We reviewed all adult patients with residual staphylococcal implant infections between January 2014 and May 2024. We analyzed the delay to rifampicin use in relation to therapeutic failures, infection recurrences, and development of ultimate rifampicin resistance. Results: Among 103 independent infection episodes, 47 (46%) contained the pathogen S. aureus, and the remainder were different coagulase-negative staphylococci. The median number of surgical interventions was one, and the median duration of postsurgical systemic antibiotic treatment was 84 days (interquartile range (IQR), 42–84 d). The median daily dose of oral rifampicin was 900 mg, and the median delay in its introduction was 5 days (IQR, 3–8 d). Overall, 18% of patients experienced an adverse event related to rifampicin (mostly gastrointestinal), requiring treatment to be stopped. The incidences of clinical failures and of microbiologically identical recurrences were 27% and 10%, respectively. The risk of rifampin resistance among any new staphylococcal infection or colonization during a median follow-up of 1.9 years was 1%. In the multivariate Cox regression analysis, the delay in rifampicin administration, its dose, or its duration failed to alter outcomes. Conclusions: In our retrospective cohort of staphylococcal orthopedic implant infections, the timing of rifampicin introduction failed to alter clinical and microbiological outcomes.

Background/Objectives: Current international guidelines recommend choosing an empirical antibiotic regimen for treating diabetic foot infections (DFI) based largely on clinical severity of the infection and local microbiological epidemiology. This may lead to selecting unnecessarily broad-spectrum initial empiric antibiotic therapy. Methods: Using data from our hospital in a large Swiss city, we retrospectively analyzed the performance of the Gram-stained smears of predominantly deep surgical DFI specimens processed by our microbiology laboratory in predicting the microorganism grown on standard cultures. We excluded episodes with paucibacillary stain results, which we interpret as contamination. Results: Among 1235 operated moderates or severe DFIs, Gram-stained smear was reported in 321 (26%) of cases, and showed bacteria in 172 episodes (54%) of these. Overall, among Gram stain results with organism seen, the sensitivity, specificity, accuracy, positive and negative predictive values of the Gram stain smear when compared with the cultures was 56%, 93%, 97%, and 38%, respectively. The accuracy was 73%. The corresponding statistical values specifically for Gram-negative bacteria were 61%, 97%, 50%, and 82%. Conclusions: The results of routine Gram stain smears of deep intraoperative DFI specimens generally lack sufficient sensitivity, and was only useful to reasonably exclude a DFI caused predominantly by Gram-negative bacteria. For Gram-stained smears results to be useful for guiding antibiotic stewardship, we need prospective trials to assess their value in different types of DFIs.

INTRODUCTION:Diabetic foot infections (DFIs) and diabetic foot osteomyelitis (DFO) are common and serious complications in patients with diabetes, often leading to severe morbidity (including amputation) and even mortality. Professional footcare, prompt diagnosis and appropriate treatment are crucial to preventing limb loss and improving outcomes in infections. AREAS COVERED:This narrative review addresses the management of all DFIs, including the approach to clinical evaluation, appropriate diagnostic methods, and optimal therapeutic strategies. We specifically address key areas in antibiotic therapy, and surgical interventions and techniques. Based on our literature review and extensive, multidisciplinary experience, we developed a novel treatment flowchart specifically for the management of DFO. EXPERT OPINION:Managing DFIs, including DFO, requires a multidisciplinary approach tailored to each patient's clinical presentation. While antibiotics, surgery, and wound care each play a crucial role, the decision-making process should always consider the infection's severity and chronicity. Our proposed flowchart for DFO management emphasizes the importance of logically-sequenced, easy to apply and tailored interventions to prevent unnecessary amputations and improve outcomes. Further research is needed to further refine this flowchart in clinical practice and demonstrate its effectiveness.

Background: The drivers for satisfaction of patients after spinal surgeries are largely unknown and potentially responsive to non-medical factors. We investigated medical and non-medical drivers for patient satisfaction and fulfillment of expectations after spinal surgery. Methods: We performed a questionnaire-based postoperative survey from May-December 2021. Overall, 400 questionnaires were sent within 3 to 6 weeks after adult spine surgery. The survey contained 33 variables (basic demographic (n = 6), health state (n = 6), satisfaction with change after spine surgery (n = 5), and satisfaction with non-medical (n = 9) variables. The primary outcome was global satisfaction of change after spinal surgery (>50th percentile of question). Results: The return rate of questionnaires was 42% (n = 167). The internal consistency of the questionnaire was acceptable (Cronbach's alpha 0.59 [range 0.49-0.68]). The current health and satisfaction with change of current health after spine surgery showed mostly strong correlations (mobility: rho 0.67; self-care: 0.74; usual activities: 0.73; pain: 0.73; anxiety: 0.79; p < 0.001 each). Pain was most commonly ranked as the most important factor for satisfaction (n = 56 [58%]), mobility as second (n = 42 [43%]), and friendliness as third (n = 27 [28%]) most important. Surprisingly, radiological proof of successful surgery was most commonly ranked last (n = 51 [53%]]. Patients with fulfillment of their expectations were more likely to have been satisfied with mobility after spine surgery (odds ratio 2.2 [95% Confidence Interval (CI]] 1.3-3.7) and friendliness of the surgeon (1.8 [95% CI 1.1-2.8)]. Conclusion: Aside from the known medical driver, mobility, for satisfaction and fulfillment of patient’s expectations, friendliness of the surgeon is shown to play an important role. Surprisingly, other non-medical factors, such as patient’s knowledge about radiological proof of successful surgery, the role of nurses and guest relations did not play an important role in this patient cohort.

Background/Objectives: Almost all orthopedic infections require a combination of surgical debridement with targeted antimicrobial treatment. The number of debridement procedures may vary considerably between infection episodes. The case mix is large, and so-called "second looks" are frequent. We investigate which bacteria are associated with second looks to achieve local infection control. Methods: We used a composite database stemming from three prospective randomized controlled trials (RCTs) from 2019 to 2025 with protocoled surgical debridement (initial debridement). In these RCTs, we allowed additional debridement only in the case of persistent or progressive local infection. Results: Overall, 201/1067 (18.8%) orthopedic infections required multiple debridement procedures. The median number of additional debridement procedures was two across all pathogen groups, with a range of 2-8 interventions. Gram-negative pathogens revealed the highest risk for "second looks" (28.2%), followed by implant-related infections (25.4%). Cutibacteria yielded the lowest risk (11.7%). In the multivariable logistic regression model, Gram-negative infections (OR 2.04, 95%CI 1.20-3.47) and infected implants (OR 2.18, 95%CI 1.56-3.03) were independently associated with multiple interventions, in contrast to Staphylococcus aureus, Enterococci, or Streptococci. Conclusions: Gram-negative pathogens were significantly associated with the need for second looks in orthopedic infections. The findings support preoperative counseling, antibiotic stewardship, and operative planning for staged management in infection cases with a high risk of clinical failure. Trials registrations: NCT04048304, NCT04081792, NCT05499481.

Background: In orthopedic surgery, we overlook the proportion of surgical site infections (SSI) acquired Intra- versus postoperative. A better overview would help to allocate resources for infection control instead of solely aiming for the perioperative period. Methods: We make use of prospective our database composed of four prospective-randomized clinical interventional trials and surveillance registers and concentrate on acute SSIs. We evaluate each SSIs clinically by searching medical and nursing notes for potential postoperative events that could plausibly cause a postoperative acquisition of bacteria. Results: Among 370 cases, we estimated 241 SSIs (65%) to be acquired intraoperatively, and 129 (35%) postoperatively. There was a clear gradient from the shoulder to the (diabetic) foot, with the shoulder yielding the highest plausible part of intraoperative SSIs (93%) and the foot the least (29%). By excluding foot SSIs, the proportion of estimated intraoperative SSIs rose to 83% (204/242 cases). The three most frequent reasons for postoperative SSIs were wound debridement immediately preceding infection, skin breakdowns and local surgical complications of various reasons (hematoma, dehiscence), and necrosis with a high proportion of polymicrobial foot SSIs among the postoperative origins. In contrast, hematogenous SSIs were rare (3%) and intraoperative SSIs were more often due to skin commensals. Conclusions: According to our prospective clinical evaluation, one-third of acute orthopedic SSIs were related with a postoperative complication that could potentially be the cause of SSI. By excluding adult (diabetic) foot surgeries, this postoperative proportion is reduced to one-sixth. Aside from reviewing the initial surgical justifications in high-risk patients and promoting (hand) hygiene, we require additional preventative treatments for the initial postoperative period. Clinical Trial Numbers: NCT05502380, NCT04081792, NCT05647252, NCT04048304.

IntroductionTreatment failure remains an issue in periprosthetic joint infection (PJI). Bacteriophages offer new treatment options. However, there is still a lack of evidence to better define their usefulness and administration. We report a case in which antibiotic suppression was successful only after administration of bacteriophages.Case descriptionAntibiotic suppression was the only option for a 94-year-old male with methicillin-resistant Staphylococcus aureus (MRSA) PJI of the hip and of the knee. As the hip PJI could not be suppressed adequately, bacteriophages were administered locally and systemically together with daptomycin. This combined approach led to sufficient clinical improvement for further oral antibiotic suppression, although without infection eradication.ConclusionThe administration of bacteriophages may be a valuable, less-invasive adjunct therapy to successfully suppress PJI. Bacteriophage selection, preparation and administration, however, remains associated with administrative obstacles, greatly limiting availability and practicability. Nevertheless, research and developments in this domain should be pursued, particularly considering issues with future antibiotic limitations and cost associated with treatment failure in PJI.

Objectives: To investigate the microbiological trends of community-acquired diabetic foot osteomyelitis (DFO) over the past two decades in specialized academic centres in Switzerland, Spain, and Turkey. Methods: A retrospective analysis of DFO cohorts (2000-2019) from five centres (Geneva, Zurich, Las Palmas, Barcelona, Istanbul) stratified into four periods (P1-P4) to assess microbiological changes. Results: Among 1379 DFO episodes (76% male, median age 67 years; 90% type 2 diabetes, median duration 17 years), gram-positive bacteria were identified in 82%, including Staphylococcus aureus (47%). Methicillin-resistant S. aureus (MRSA) was more prevalent in Barcelona (36%), Las Palmas (24%), and Geneva (29%) than in Zurich (7%). Over time, gram-positive bacteria remained stable or decreased, particularly in Las Palmas (83% to 65%, P = 0.03). The proportion of MRSA decreased in Geneva (39% to 16%) and Las Palmas (37% to 9%), but remained stable in Barcelona. Enterobacteriaceae prevalence increased, notably in Geneva (16% to 39%, P < 0.01) and Las Palmas (27% to 41%, P < 0.01). Among gram-negative pathogens quinolone resistance was 12.5%. Enterobacteriaceae-DFO was associated with ischemic necrosis (OR 1.65), Las Palmas cohort (OR 3.14), and 2016-2019 period (OR 2.68). Conclusions: A significant increase in Enterobacteriaceae-related DFOs was observed from 2016 to 2019, particularly in Mediterranean Europe.

ABSTRACT Background Diabetic foot ulcers in developing countries often become infected. The healthcare systems are often not equipped to conduct the culture and the sensitivity tests required for prescribing a targeted antibiotic treatment for diabetic foot infection (DFI). Methods We evaluate antibiotic stewardship programmes for DFIs, at every level of health care, with an emphasis on resource‐poor settings such as in Africa. Results The management of DFI very often is adapted to the financial and practical realities of the resource‐poor regions. The application of the point‐of‐care Gram stain of deep tissue samples is efficient, rapid, low cost and ubiquitously available. Upon the identification of the predominant pathogen in the Gram stain, a semi‐quantitative preemptive antibiotic treatment can be started in accordance with the World Health Organization Aware, Watch and Restrict Essential Medicine List. This list is catered to every country and is a powerful tool. However, some basic knowledge of the local microbiological epidemiology is necessary to choose the most appropriate agent. We report our experience on using the rapidly available Gram stain for narrowing the preemptive choice of listed antibiotic agents, as an economic tool for antibiotic stewardship in DFIs. Conclusions In the practical and resource‐saving management of DFI, the ‘therapeutic’ use of Gram stains is not common in resource‐rich countries but should be added to the arsenal of the general efforts for antibiotic stewardship.

Diabetes is a chronic disease associated with numerous complications including diabetic foot disorders, which are associated with significant morbidity and mortality as well as high costs. The costs associated with diabetic foot disorders comprise those linked to care (direct) and loss of productivity and poor quality of life (indirect). Due to the constant increase in diabetes prevalence, it is expected that diabetic foot disorder will require more resources, both in terms of caregivers and economically. We reviewed findings on management, morbidity, mortality, and costs related to diabetic foot disorder.

Despite growing numbers of scientific publications on the optimal antibiotic treatment for diabetic foot infections, the data on the adult population with non-diabetic (postsurgical) foot infections is limited. Therefore, one of the largest single-center databases at the Balgrist University Hospital in Zurich, Switzerland, was established between January 2014 and August 2022. Using a case–control study design, we retrospectively investigated failures of combined surgical and antibiotic therapy for surgical site foot infections (SSIs). Overall, 17.4% of the episodes experienced therapeutic failures, particularly in patients with infected ankle prostheses. However, age, biological sex, pathogens, the duration of post-debridement antibiotic treatment, the number of surgical debridements, or the use of negative-pressure wound care altered the failure risk. In the multivariate logistic regression analyses, the duration of postsurgical antibiotic use was completely indifferent (as a continuous variable with an odds ratio of 1.0 and a 95% confidence interval ranging from 0.96 to 1.03) when stratified into inter-tertiary groups. Our findings suggest that shorter courses of systemic antibiotics may be appropriate in non-diabetic adults, supporting better antibiotic stewardship. Ongoing randomized controlled trials are under way to investigate which patients might safely receive shorter antibiotic treatments for surgical site infections following elective foot and ankle procedures.