Topic: Prosthetic Joint Infection (PJI)

Based on the current evidence, there is no diff erence in infection rates following IM fi xation of long bone fractures using a reamed or non-reamed technique. Using an IM fi xation technique has become the accepted standard in treating long bone fractures. Tibial fractures are the most common type of long bone fracture encountered and therefore are the most studied in the current literature. Evidence has supported that IM nailing is superior to external fi xation with regards to patient outcomes; however, there has not been a consensus with regard to reamed versus non-reamed IM nailing technique. Classically, the arguments against the use of reaming point to the risk of fat embolization from the marrow-generated from the increased intramedullary pressure created during the technique, and development of acute respiratory distress syndrome (ARDS).
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Septic arthritis is an orthopaedic emergency and needs prompt surgical treatment. Based on current evidence, there are no clear indications for the timing of surgical intervention in cases of osteomyelitis. The current literature does suggest monitoring disease progression, treatment effi cacy and resolution by trending C-reactive protein (CRP) levels. The treatment of musculoskeletal infections in children has long been debated. Evidence has shown that it can be appropriate to treat this condition medically. However, surgery can play a critical therapeutic role for patients not responding to medical treatment or those presenting with massive bioburden in the joint that may require evacuation. Osteomyelitis in the pediatric population often has overlap-ping clinical features with other diseases, making its diagnosis challenging.
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Because of their associated poor clinical outcomes, unusual organisms resulting in infection should not be treated equivalently to a usual pathogenic organism. Identification of unusual organisms through molecular and genetic techniques should help aid in antibiotic selection in conjunction with surgery, as indicated. Because of the associated poor clinical outcomes of unusual organisms and polymicrobial infections, the results of these newer techniques should not be ignored, but instead used to help inform therapeutic choices. There are variety of unusual organisms that can cause periprosthetic joint infections (PJI) aside from Staphylococcus species. Unusual organisms represent about 4.5% of the PJIs in the United States, while culture‐negative infections account for 18.6% Many of these uncommon organisms, in addition to the culture‐negative organisms, are associated with polymicrobial PJIs.
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Osteonecrosis of the femoral head is a poorly understood condition that may lead to progressive destruction of the hip joint. Its incidence is common between the third and fifth decades of life and it is the diagnosis behind 5–18% of annually performed total hip arthroplasties (THAs) in the USA. Regarding the high rate of complications of THA in that age group, authors have agreed on the importance of joint-preservation techniques for this disease but techniques vary to establish a generally accepted algorithmic approach. Surgical head-preserving procedures, core decompression with or without graft, stem cell augmentation, or biologic adjuncts, vascularized bone grafting, and proximal femoral osteotomies have all been published on with heterogeneous results and with limited evidence to date.
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The Second International Consensus Meeting (ICM) on Musculoskeletal Infection was held in July 2018 in Philadelphia, Pennsylvania. This meeting involved contributions from an international multidisciplinary consortium of experts from orthopaedic surgery, infectious disease, pharmacology, rheumatology, microbiology, and others. Through strict delegate engagement in a comprehensive 13-step consensus process based on the Delphi technique, evidence-based consensus guidelines on musculoskeletal infection were developed. The 2018 ICM produced updates to recommendations from the inaugural ICM that was held in 2013, which primarily focused on periprosthetic infection of the hip and the knee, and added new guidelines with the expansion to encompass all subspecialties of orthopaedic surgery. The following proceedings from the pediatrics section are an overview of the ICM consensus recommendations on the prevention, diagnosis, and treatment of pediatric musculoskeletal infection.
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While metagenomic (microbial DNA) sequencing technologies can detect the presence of microbes in a clinical sample, it is unknown whether this signal represents dead or live organisms within a microbial community, and also if it maps expressed genes to a functional pathway of interest (e.g. antibiotic resistance.) After RNA metratranscriptomic analysis of synovial fluid and peripheral blood, differential metatranscrptomic signatures for infected vs. noninfected cohorts enabled us to train machine learning algorithms to 84.9% predictive accuracy for infection. A variety of antibiotic resistance genes were also expressed, with high concordance to conventional antibiotic sensitivity data.
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