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Fracture‐related infection (FRI) is a serious complication following musculoskeletal trauma. Accurate diagnosis and appropriate treatment depend on retrieving adequate deep tissue biopsies for bacterial culture. The aim of this cohort study was to compare intraoperative tissue cultures obtained by the Reamer‐Irrigator‐Aspirator system (RIA)‐system against standard tissue cultures obtained during the same surgical procedure. All patients had long bone fractures of the lower limbs and were assigned to the FRI or Control group based on the FRI consensus definition. The FRI group consisted of 24 patients with confirmed FRI and the Control group consisted of 21 patients with aseptic nonunion or chronic pain (in the absence of other suggestive/confirmatory criteria). Standard tissue cultures and cultures harvested by the RIA‐system showed similar results. In the FRI group, standard tissue cultures and RIA cultures revealed relevant pathogens in 67% and 71% of patients, respectively. Furthermore, in four FRI patients, cultures obtained by the RIA‐system revealed additional relevant pathogens that were not found by standard tissue culturing, which contributed to the optimization of the treatment plan. In the Control group, there were no false‐positive RIA culture results. As a proof‐of‐concept, this cohort study showed that the RIA‐system could have a role in the diagnosis of FRI as an adjunct to standard tissue cultures. Since scientific evidence on the added value of the RIA‐system in the management of FRI is currently limited, further research on this topic is required before its routine application in clinical practice. [ABSTRACT FROM AUTHOR]

Antibiotic‐loaded bone cement (ALBC) is broadly used to treat orthopaedic infections based on the rationale that high‐dose local delivery is essential to eradicate biofilm‐associated bacteria. However, ALBC formulations are empirically based on drug susceptibility from routine laboratory testing, which is known to have limited clinical relevance for biofilms. There are also dosing concerns with nonstandardized, surgeon‐directed, hand‐mixed formulations, which have unknown release kinetics. On the basis of our knowledge of in vivo biofilms, pathogen virulence, safety issues with nonstandardized ALBC formulations, and questions about the cost‐effectiveness of ALBC, there is a need to evaluate the evidence for this clinical practice. To this end, thought leaders in the field of musculoskeletal infection (MSKI) met on 1 August 2019 to review and debate published and anecdotal information, which highlighted four major concerns about current ALBC use: (a) substantial lack of level 1 evidence to demonstrate efficacy; (b) ALBC formulations become subtherapeutic following early release, which risks induction of antibiotic resistance, and exacerbated infection from microbial colonization of the carrier; (c) the absence of standardized formulation protocols, and Food and Drug Administration‐approved high‐dose ALBC products to use following resection in MSKI treatment; and (d) absence of a validated assay to determine the minimum biofilm eradication concentration to predict ALBC efficacy against patient specific micro‐organisms. Here, we describe these concerns in detail, and propose areas in need of research. [ABSTRACT FROM AUTHOR]

Background: Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF's.Methods: This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months.Discussion: Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility.Trial Registration: ClinicalTrials.gov : NCT03598530 . [ABSTRACT FROM AUTHOR]

Antimicrobial resistance (AMR) is widely regarded as one of the most important global public health challenges of the twenty-first century. The overuse and the improper use of antibiotics in human medicine, food production, and the environment as a whole have unfortunately contributed to this issue. Many major international scientific, political, and social organizations have warned that the increase in AMR could cost the lives of millions of people if it is not addressed on a global scale. Although AMR is already a challenge in clinical practice today, it has taken on a new importance in the face of the coronavirus disease 2019 (COVID-19) pandemic. While improved handwashing techniques, social distancing, and other interventional measures may positively influence AMR, the widespread use of antibiotics to treat or prevent bacterial coinfections, especially in unconfirmed cases of COVID-19, may have unintended negative implications with respect to AMR. Although the exact number of bacterial coinfections and the rate at which patients with COVID-19 receive antibiotic therapy remain to be accurately determined, the pandemic has revived the discussion on antibiotic overuse and AMR. This article describes why the COVID-19 pandemic has increased our awareness of AMR and presents the immense global impact of AMR on society as a whole. Furthermore, an attempt is made to stress the importance of tackling AMR in the future and the role of the orthopaedic community in this worldwide effort. [ABSTRACT FROM AUTHOR]

Bone infection represents a serious complication of orthopedic surgery and Staphylococcus aureus is the most common pathogen. To improve the understanding of host‐pathogen interaction, we developed a biospecimen registry (AO Trauma CPP Bone Infection Registry) to collect clinical data, bacterial isolates, and serum from patients with S. aureus bone infection. A prospective multinational registry with a 12‐month follow‐up was created to include adult patients (18 years or older) with culture‐confirmed S. aureus infection in long bones after fracture fixation or arthroplasty. Baseline patient attributes and details on infections and treatments were recorded. Blood and serum samples were obtained at baseline, 6, and 12 months. Patient‐reported outcomes were collected at 1, 6, and 12 months. Clinical outcomes were recorded. Two hundred and ninety‐two patients with fracture‐related infection (n = 157, 53.8%), prosthetic joint infection (n = 86, 29.5%), and osteomyelitis (n = 49, 16.8%) were enrolled. Methicillin‐resistant S. aureus was detected in 82 patients (28.4%), with the highest proportion found among patients from North American sites (n = 39, 48.8%) and the lowest from Central European sites (n = 18, 12.2%). Patient outcomes improved at 6 and 12 months in comparison to baseline. The SF‐36 physical component summary mean (95% confidence interval) score, however, did not reach 50 at 12 months. The cure rate at the end of the study period was 62.1%. Although patients improved with treatment, less than two‐thirds were cured in 1 year. At 12‐month follow‐up, patient‐reported outcome scores were worse for patients with methicillin‐resistant S. aureus infections. [ABSTRACT FROM AUTHOR]

Background: Timing of surgery in geriatric hip fracture treatment remains controversial. Early surgery is acknowledged as a quality indicator and NICE guidelines recommend surgery within 0–48 h from admission. In 2014 we implemented the indicator of early surgery in our institution, enhancing operative treatment within the next calendar day. We aimed to evaluate the implementation, define the room for improvement and provide strategies to maintain the quality indicator. Methods: Clinical outcome of 744 patients (January 2011–December 2013) before early surgery was implemented, compared to 817 patients (June 2014–May 2017) after implementation of early surgery with a follow-up of 6 months. Data-analysis was done by Pearson's Chi-square test and Mann–Whitney U test. Results: Early surgery was achieved in 47.6% and 85.7% in the preimplementation and postimplementation group, respectively (P < 0.001). Both 30 days and 6 months mortality were similar (6.0% vs. 5.4%, P = 0.573 and 18.7% vs. 16.9%, P = 0.355, preimplementation vs. postimplementation, respectively). Early surgery resulted in a significantly shorter total length-of-stay (14 vs. 12 days, P < 0.001, preimplementation vs. postimplementation, respectively). Early surgery did not reduce the readmission rate. Conclusions: The indicator of early surgery has been successfully implemented. Early surgery resulted in a significantly shorter LOS. No significant reduction in 30 days and 6 months mortality, and 90 days readmission was observed. To maintain early surgery, continuous engagement and monitoring is required by all shareholders involved and if necessary, adjustment of the clinical route is appropriate. [ABSTRACT FROM AUTHOR]

Bacteriophage therapy has recently attracted increased interest, particularly in difficult-to-treat infections. Although it is not a novel concept, standardized treatment guidelines are currently lacking. We present the first steps towards the establishment of a "multidisciplinary phage task force" (MPTF) and a standardized treatment pathway, based on our experience of four patients with severe musculoskeletal infections. After review of their medical history and current clinical status, a multidisciplinary team found four patients with musculoskeletal infections eligible for bacteriophage therapy within the scope of Article 37 of the Declaration of Helsinki. Treatment protocols were set up in collaboration with phage scientists and specialists. Based on the isolated pathogens, phage cocktails were selected and applied intraoperatively. A draining system allowed postoperative administration for a maximum of 10 days, 3 times per day. All patients received concomitant antibiotics and their clinical status was followed daily during phage therapy. No severe side-effects related to the phage application protocol were noted. After a single course of phage therapy with concomitant antibiotics, no recurrence of infection with the causative strains occurred, with follow-up periods ranging from 8 to 16 months. This study presents the successful outcome of bacteriophage therapy using a standardized treatment pathway for patients with severe musculoskeletal infection. A multidisciplinary team approach in the form of an MPTF is paramount in this process. [ABSTRACT FROM AUTHOR]

Bone healing is a complicated process of tissue regeneration that is influenced by multiple biological and biomechanical processes. In a minority of cases, these physiological processes are complicated by issues such as nonunion and/or fracture-related infection (FRI). Based on a select few in vivo experimental animal studies, construct stability is considered an important factor influencing both prevention and treatment of FRI. Stephan Perren played a pivotal role in the evolution of our current understanding of the critical relationship between biomechanics, fracture healing and infection. Furthermore, his concept of strain theory and the process of fracture healing is familiar to several generations of surgeons and has influenced implant development and design for the past 50 years. In this review we describe the role of biomechanical stability on fracture healing, and provide a detailed analysis of the preclinical studies addressing this in the context of FRI. Furthermore, we demonstrate how Perren's concepts of stability are still applied to current surgical techniques to aid in the prevention and treatment of FRI. Finally, we highlight the key knowledge gaps in the underlying basic research literature that need to be addressed as we continue to optimize patient care., Competing Interests: Declaration of Competing Interest All authors declare no conflict of interest with respect to the preparation and writing of this article., (Copyright © 2020. Published by Elsevier Ltd.)

Orthopaedic and trauma device-related infection (ODRI) remains one of the major complications in modern trauma and orthopaedic surgery.Despite best practice in medical and surgical management, neither prophylaxis nor treatment of ODRI is effective in all cases, leading to infections that negatively impact clinical outcome and significantly increase healthcare expenditure.The following review summarises the microbiological profile of modern ODRI, the impact antibiotic resistance has on treatment outcomes, and some of the principles and weaknesses of the current systemic and local antibiotic delivery strategies.The emerging novel strategies aimed at preventing or treating ODRI will be reviewed. Particular attention will be paid to the potential for clinical impact in the coming decades, when such interventions are likely to be critically important.The review focuses on this problem from an interdisciplinary perspective, including basic science innovations and best practice in infectious disease. Cite this article: Moriarty TF, Kuehl R, Coenye T, et al. Orthopaedic device related infection: current and future interventions for improved prevention and treatment. EFORT Open Rev 2016;1:89-99. DOI: 10.1302/2058-5241.1.000037., Competing Interests: Conflict of Interest: None declared.