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Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_17 | Pages 1 - 1
24 Nov 2023
Hotchen A Wismayer M Dudareva M Sigmund IK McNally M
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Aim

To compare outcomes of PJI in relation to treatment method versus classification using the JS-BACH system.

Method

Patients having surgery for EBJIS Criteria Confirmed PJI between 2010–2015 were included. Index surgical procedures were 1-stage or 2-stage revision or debridement and implant retention (DAIR). Patients completed the EuroQol EQ-5D-3L questionnaire and were followed clinically to a median of 4.7 years (IQR 2.7–6.7 years). Patients were stratified using the JS-BACH classification1 into either ‘Uncomplicated’, ‘Complex’ or having ‘Limited treatment options’, by two separate classifiers, blinded to clinical outcome.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_17 | Pages 56 - 56
24 Nov 2023
Hotchen A Dudareva M Frank F Sukpanichy S Corrigan R Ferguson J Stubbs D McNally M
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Aim

To investigate the impact of waiting for surgical treatment for bone and joint infection (BJI) on patient self-reported quality of life (QoL).

Method

Patients presenting to clinic between January 2019 and February 2020 completed the EuroQol EQ-5D-5L questionnaire. Patients were divided into three groups: surgery performed; on the waiting list for surgery; or decision for non-operative management. All patients were followed-up for 2 years. The EQ-index score was calculated and change from presentation to 1-year and 2-year follow-up was compared across the 3 groups. Mortality at final follow-up was measured in all groups.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_17 | Pages 3 - 3
24 Nov 2023
Dinh A Chatillon ED Ho R McNally M Dudareva M Scarborough M Jesuthasan G Escolà-Vergé L Lora-Tamayo J Mancheño-Losa M Thill P Giordano G Fourcade C Duran C Bonnet E Hascoet JL
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Aim

Prosthetic joint infection (PJI) due to Candida spp. is a severe complication of arthroplasty but is little reported. This study describes Candida PJI epidemiology, management, and outcome.

Method

We performed a retrospective, observational multinational study with support of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Patients diagnosed with PJI due to Candida spp. between 1990 and 2021 were included. Demographic, clinical, laboratory, imaging, medical/surgical treatment, and outcome data were collected within a standardized database. Treatment failure was defined either as a Candida infection recurrence, superinfection, or death due to infection.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_17 | Pages 50 - 50
24 Nov 2023
Hotchen A Tsang SJ Dudareva M Sukpanichy S Corrigan R Ferguson J Stubbs D McNally M
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Aim

Patient quality of life (QoL) in untreated bone infection was compared to other chronic conditions and stratified by disease severity.

Method

Patients referred for treatment of osteomyelitis (including fracture related infection) were identified prospectively between 2019 and 2023. Patients with confirmed infection completed the EuroQol EQ-5D-5L questionnaire. Clinicians blinded to EQ-index score, grouped patients according to JS-BACH Classification into ‘Uncomplicated’, ‘Complex’ or ‘Limited treatment options’. A systematic review of the literature was performed of other conditions that have been stratified using EQ-index score.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 34 - 34
1 Oct 2022
Dudareva M Corrigan R Hotchen A Muir R Scarborough C Kumin M Atkins B Scarborough M McNally M Collins G
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Aim

Smoking is known to impair wound healing and to increase the risk of peri-operative adverse events and is associated with orthopaedic infection and fracture non-union. Understanding the magnitude of the causal effect on orthopaedic infection recurrence may improve pre-operative patient counselling.

Methods

Four prospectively-collected datasets including 1173 participants treated in European centres between 2003 and 2021, followed up to 12 months after surgery for clinically diagnosed orthopaedic infections, were included in logistic regression modelling with Inverse Probability of Treatment Weighting for current smoking status [1–3]. Host factors including age, gender and ASA score were included as potential confounding variables, interacting through surgical treatment as a collider variable in a pre-specified structural causal model informed by clinical experience. The definition of infection recurrence was identical and ascertained separately from baseline factors in three contributing cohorts. A subset of 669 participants with positive histology, microbiology or a sinus at the time of surgery, were analysed separately.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 76 - 76
1 Oct 2022
Russell C Tsang SJ Dudareva M Simpson H Sutherland R McNally M
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Aim

Pelvic osteomyelitis following pressure ulceration results in substantial patient morbidity. Previous studies have reported a heterogenous approach to diagnosis and medical management by physicians, suggesting equipoise on key clinical questions. This study hypothesised that the same equipoise exists amongst Orthopaedic surgeons.

Method

An 18-question multiple-choice questionnaire was designed through an iterative feedback process until the final version was agreed by all authors. Likert-type scale responses were used with graded responses (e.g., never/fewer than half of patients/around half of patients/more than half of patients/every patient). The online survey was sent to members of the Musculoskeletal Infection Society (MSIS), the European Bone and Joint Infection Society (EBJIS), and the ESCMID Study Group for Implant-Associated Infections (ESGIAI). No incentive for participation was provided.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 44 - 44
1 Oct 2022
Young B Dudareva M Vicentine M Hotchen A McNally M
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Aim

Local antibiotic treatment for bone and joint infections offers direct delivery of high concentrations of antibiotics with reduced systemic exposure and favourable safety profile. However, the possibility of prolonged release of antibiotics at sub-therapeutic levels creates concern about the possible development of antimicrobial resistance.

We investigated patients with recurrent bone and joint infection for evidence of antimicrobial resistance emerging from the use of local antibiotics.

Method

125 patients with recurrent infection (prosthetic joint infection, fracture related infection and osteomyelitis) in the UK between 2007 and 2021 were identified. Electronic patient records (including operative notes, pathology results and prescriptions) were reviewed to extract site of infection, date of surgery, the use of local antibiotics, culture results, empiric and definitive antibiotic therapy. All antibiotic sensitivity results were recorded as sensitive, intermediate or resistant according to contemporary guidelines (BSAC and EUCAST).


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 84 - 84
1 Oct 2022
Sliepen J Corrigan R Dudareva M Wouthuyzen-Bakker M Rentenaar R Atkins B Hietbrink F Govaert G McNally M Ijpma F
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Background

Fracture-related infection (FRI) is treated by adequate debridement, lavage, fracture stabilization (if indicated), adequate soft tissue coverage and systemic antimicrobial therapy. Additional administration of local antibiotics (LA), placed directly in the surgical field, is thought to be beneficial for successful eradication of infection.

Aims

1) To evaluate the effect of local antibiotics on outcome in patients with FRI. 2) To evaluate whether bacterial resistance to the implanted local antibiotics influences its efficacy.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 57 - 57
1 Oct 2022
Young B Dudareva M Vicentine M Hotchen A McNally M
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Aim

We reviewed a cohort of individuals with recurrent orthopaedic infection to describe the relative rates of microbial persistence vs re-infection at recurrence surgery.

Method

A cohort of 125 individuals with recurrent infection (prosthetic joint infection, fracture-related infection and osteomyelitis) from two centres in the UK between 2007 and 2021. Electronic patient records were reviewed to identify culture results from surgical samples at index surgery and the next operation for recurrent infection. Antibiotic sensitivity results were recorded as sensitive, intermediate or resistant according to contemporary sensitivity testing guidelines.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 60 - 60
1 Oct 2022
Dudareva M Corrigan R Hotchen A Muir R Sattar A Scarborough C Kumin M Atkins B Scarborough M McNally M Collins G
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Aim

Recurrence of bone and joint infection, despite appropriate therapy, is well recognised and stimulates ongoing interest in identifying host factors that predict infection recurrence. Clinical prediction models exist for those treated with DAIR, but to date no models with a low risk of bias predict orthopaedic infection recurrence for people with surgically excised infection and removed metalwork. The aims of this study were to construct and internally validate a risk prediction model for infection recurrence at 12 months, and to identify factors that predict recurrence. Predictive factors must be easy to check in pre-operative assessment and relevant across patient groups.

Methods

Four prospectively collected datasets including 1173 participants treated in European centres between 2003 and 2021, followed up to 12 months after surgery for orthopaedic infections, were included in logistic regression modelling [1–3]. The definition of infection recurrence was identical and ascertained separately from baseline factors in three contributing cohorts. Eight predictive factors were investigated following a priori sample size calculation: age, gender, BMI, ASA score, the number of prior operations, immunosuppressive medication, glycosylated haemoglobin (HbA1c), and smoking. Missing data, including systematically missing predictors, were imputed using Multiple Imputation by Chained Equations. Weekly alcohol intake was not included in modelling due to low inter-observer reliability (mean reported intake 12 units per week, 95% CI for mean inter-rater error −16.0 to +15.4 units per week).


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 13 - 13
1 Oct 2022
Corrigan R Dudareva M Sliepen J Wouthuyzen M Rentenaar R Ijpma F Hietbrink F Atkins B Govaert G McNally M
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Aim

Fracture related infection (FRI) is classically defined as early (0–2 weeks), delayed (3–10 weeks) or late (>10 weeks). Treatment strategies reflect this, particularly with debridement and implant retention (DAIR), but there is little evidence to support this. This multinational study clarified the relationship between pathogens isolated and time from injury.

Methods

All confirmed FRI cases, managed surgically, at three hospitals were included. Data were analyzed on patient demographics, time from injury and pathogens isolated. Patients who underwent DAIR were also analyzed separately.


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_15 | Pages 57 - 57
1 Dec 2021
Hotchen A Dudareva M Corrigan R Faggiani M Ferguson J Atkins B Bernard A McNally M
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Aim

To compare pre-referral microbiology and previous bone excision in long bone osteomyelitis with intra-operative microbiology from a specialist centre.

Method

A prospective observational cohort study of patients referred to a single tertiary centre who met the following criteria: (i) aged ≥18 years, (ii) received surgery for long bone osteomyelitis and (iii) met diagnostic criteria for long bone osteomyelitis. Patient demographics, referral microbiology and previous surgical history were collected at the time of initial clinic appointment. During surgery, a minimum of 5 intra-operative deep tissue samples were sent for microbiology. Antimicrobial options were classified from the results of susceptibility testing using the BACH classification of long bone osteomyelitis as either Ax (unknown or culture negative), A1 (good options available) or A2 (limited options available). The cultures and susceptibility of pre-referral microbiology were compared to the new intra-operative sampling results. In addition, an association between previous osteomyelitis excision and antimicrobial options were investigated.


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_15 | Pages 80 - 80
1 Dec 2021
Hotchen A Dudareva M Corrigan R Faggiani M Ferguson J McNally M
Full Access

Aim

To investigate self-reported quality of life (QoL) in patients with osteomyelitis referred to a specialist centre in the UK and investigate the relationship between QoL and BACH classification.

Method

All patients newly referred to a specialist bone infection clinic at a single tertiary centre within the UK between January 2019 and February 2020 were prospectively included. Diagnosis of osteomyelitis was made according to the presence of clinical and radiological criteria for ≥6 months. An EQ-5D-5L questionnaire and visual analogue score (VAS) were completed during the initial clinic appointment. Long-bone osteomyelitis was classified by the attending orthopaedic surgeon using the BACH classification system as either uncomplicated, complex or with limited options available.1 Patients managed non-operatively were subclassified into those who were (i) unfit to receive an operation or (ii) fit and well with stable disease. EQ-5D index scores were compared to a published UK value set of 41 chronic health conditions within the UK.2


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_15 | Pages 44 - 44
1 Dec 2021
Dudareva M Vallis C Dunsmure L Scarborough M
Full Access

Aim

Fungal orthopaedic infections most commonly affect people with complex surgical histories and existing comorbidities. Recurrence and re-infection rates are high, even with optimal surgical and systemic antifungal treatment. AmBisome liposomal amphotericin B has been suggested for local antifungal therapy, as an adjunctive treatment for fungal osteoarticular infections. Few case series have examined its clinical use when combined with polymethylmethacrylate cement PMMA), or with absorbable local antibiotic carriers.

We aimed to evaluate the clinical use of local antifungal therapy with AmBisome liposomal amphotericin B (ABlaB), including tolerated doses, serious adverse events, and treatment outcomes.

Method

A retrospective cohort of all patients treated with local antifungal therapy with ABlaB between January 2016 and January 2021 in a specialist orthopaedic hospital was identified using pharmacy records.

Renal function, serious adverse events during treatment, surgical outcomes including spacer fracture and infection recurrence, were identified from electronic clinical records. The project was approved by the Institutional Review Board (clinical audit 6871).


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_6 | Pages 22 - 22
1 May 2021
Hotchen A Dudareva M Corrigan R Faggiani M Ferguson J McNally M
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Introduction

This study assesses self-reported quality of life (QoL) in patients with osteomyelitis referred to a specialist centre in the UK.

Materials and Methods

All patients newly referred to a specialist tertiary bone infection clinic within the UK between January 2019 and February 2020 were prospectively included. Diagnosis of osteomyelitis was made according to the presence of clinical and radiological criteria for ≥6 months. An EQ-5D-5L questionnaire and visual analogue score (VAS) were completed during the initial clinic appointment. Long-bone osteomyelitis was classified by the attending orthopaedic surgeon using the BACH classification system as either uncomplicated, complex or with limited options available. Patients managed non-operatively were subclassified into those who were (i) unfit to receive an operation or (ii) fit and well with stable disease. EQ-5D index scores were compared to a published UK value-set of 41 chronic health conditions within the UK.


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_6 | Pages 23 - 23
1 May 2021
Hotchen A Dudareva M Corrigan R Faggiani M Ferguson J Atkins B McNally M
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Introduction

Patients with long-bone osteomyelitis are frequently referred with limited microbiological information. This study compared pre-referral microbiology in long bone osteomyelitis with intra-operative microbiology from a specialist centre.

Materials and Methods

All patients referred to a single tertiary centre between February 2019 and February 2020, aged ≥18 years and received surgery for confirmed long-bone osteomyelitis were included. Patient demographics, referral microbiology and previous surgical history were collected at the time of initial clinic appointment. During surgery, a minimum of 5 intra-operative deep tissue samples were sent for microbiology. Antimicrobial options were classified from the results of susceptibility testing using the BACH classification of long bone osteomyelitis as either Ax (unknown or culture negative), A1 (good options available) or A2 (limited options available). The cultures and susceptibility of pre-referral microbiology were compared to the new intra-operative sampling results. In addition, an association between previous osteomyelitis excision and antimicrobial options were investigated.


The Bone & Joint Journal
Vol. 102-B, Issue 11 | Pages 1587 - 1596
1 Nov 2020
Hotchen AJ Dudareva M Corrigan RA Ferguson JY McNally MA

Aims

This study presents patient-reported quality of life (QoL) over the first year following surgical debridement of long bone osteomyelitis. It assesses the bone involvement, antimicrobial options, coverage of soft tissues, and host status (BACH) classification as a prognostic tool and its ability to stratify cases into ‘uncomplicated’ or ‘complex’.

Methods

Patients with long-bone osteomyelitis were identified prospectively between June 2010 and October 2015. All patients underwent surgical debridement in a single-staged procedure at a specialist bone infection unit. Self-reported QoL was assessed prospectively using the three-level EuroQol five-dimension questionnaire (EQ-5D-3L) index score and visual analogue scale (EQ-VAS) at five postoperative time-points (baseline, 14 days, 42 days, 120 days, and 365 days). BACH classification was applied retrospectively by two clinicians blinded to outcome.


The Bone & Joint Journal
Vol. 102-B, Issue 7 | Pages 904 - 911
1 Jul 2020
Sigmund IK Dudareva M Watts D Morgenstern M Athanasou NA McNally MA

Aims

The aim of this study was to evaluate the diagnostic value of preoperative serum CRP, white blood cell count (WBC), percentage of neutrophils (%N), and neutrophil to lymphocyte ratio (NLR) when using the fracture-related infection (FRI) consensus definition.

Methods

A cohort of 106 patients having surgery for suspected septic nonunion after failed fracture fixation were studied. Blood samples were collected preoperatively, and the concentration of serum CRP, WBC, and differential cell count were analyzed. The areas under the curve (AUCs) of diagnostic tests were compared using the z-test. Regression trees were constructed and internally cross-validated to derive a simple diagnostic decision tree.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_14 | Pages 92 - 92
1 Dec 2019
Sigmund IK Morgenstern M Dudareva M Athanasou N McNally M
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Background

Preoperative diagnosis of fracture related infections can be challenging, especially when confirmatory criteria such as sinus tract and purulent discharge are absent. Although serum parameters, such as CRP and white blood cell count (WBC), showed poor accuracy in the literature, they are still often used in clinical practice. The European Bone and Joint Infection Society (EBJIS) defined evidence-based criteria for fracture related infection. Elevated serum inflammatory markers were regarded as suggestive criteria only, as the literature was of limited quality. This study assessed the diagnostic value of the serum parameters CRP, WBC and differential cell count in the diagnosis of fracture related infections defined by the EBJIS-criteria for fracture related infections.

Methods

In this retrospective cohort study, 94 patients who underwent surgical treatment for suspected infected non unions after failed fracture fixation were included. Preoperatively, blood samples including serum inflammatory markers were taken. For this study, cut-offs of 5 mg/L for CRP, 10×10⁁9 cells/L for WBC, and >70% for the percentage of neutrophils were regarded as positive for infection. All patients had intraoperative samples taken for microbiology and histology. Analysis of diagnostic accuracy was based on the receiver-operating characteristic (ROC).


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_14 | Pages 60 - 60
1 Dec 2019
Hotchen A Dudareva M Ferguson J Rombach I Scarborough M McNally M
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Aim

Bone and joint infections are a serious complication of trauma, surgery and soft tissue infections. However, there are few data presenting patient reported outcome measures for osteomyelitis. A recently proposed method for classification of osteomyelitis, BACH, stratifies patients into ‘uncomplicated’ and ‘complex’, based on four key inter-disciplinary components: Bone involvement, Anti-microbial options, soft-tissue Coverage and Host status. We aim to correlate the classification severity with patient reported outcomes following osteomyelitis surgery.

Method

Seventy-one patients with long-bone osteomyelitis, confirmed using a validated composite protocol, were included. Patients received a single-stage procedure at a specialist bone infection unit. Euro-Qol EQ-5D-3L questionnaires and Visual Analogue Scores (VAS) (0–100) were collected prospectively at baseline, 14 days, 6 weeks, 4 months and 1 year post-operatively. The EQ-5D-3L index score, a composite measure of performance of daily activities, was calculated from the 5 domains of the EQ-5D-3L. BACH was applied retrospectively by two independent clinicians blinded to all patient outcomes.