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Paper of the week: Stopping antibiotics after surgical amputation in diabetic foot and ankle infections-A daily practice cohort.

Paper of the week: Stopping antibiotics after surgical amputation in diabetic foot and ankle infections-A daily practice cohort. Rossel A, Lebowitz D, Gariani K, Abbas M, Kressmann B, Assal M, Tscholl P, Stafylakis D, Uçkay I. Endocrinol Diabetes Metab. 2019 Feb 6;2(2): e00059. doi: 10.1002/edm2.59. eCollection 2019 Apr.

Summary by Dr. Sreeram Penna

This is a retrospective cohort study included adult diabetic foot and ankle infection patients who underwent amputation. Researchers studied benefits of continuing antibiotics after amputation. Overall 482 episodes in 258 patients were included in the study. Osteomyelitis was diagnosed in 239 cases. Median duration of antibiotics post amputation was 7 days. In 109 episodes antibiotic was discontinued immediately after surgery. Using multivariate analysis researchers concluded that neither duration of post-operative antibiotics (Hazards ratio: 1.0; CI 0.99 – 1.01) nor immediate discontinuation (Hazards ratio: 0.9; CI 0.5 -1.5) altered overall failure rate. Researchers also stressed importance of amputation with clear margins.

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The 23 Greatest Research Priorities in Musculoskeletal Infection

By Dr. Edward Schwarz

Musculoskeletal infections (MSKI) remain the bane of orthopaedic surgery, resulting in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis and treatment remain largely unchanged over the last fifty years, a 2nd International Consensus Meeting on MSKI (ICM 2018) was completed on July 25-27, 2018 in Philadelphia, PA, USA. This 2-year long process derived the final set of 652 consensus questions, which were discussed and voted on by 658 scientists, internists and orthopaedic surgeons representing 92 countries. As critical outcomes of ICM 2018 include determining the current incidence and costs of MSKI, establishing what is currently known about the basic science of MSKI and effective standards of care, and deriving the greatest research priorities, two ICM 2018 research workgroups (RW) were assembled to accomplish these tasks. The findings appear in the May 2019 issue of the Journal of Orthopaedic Research.

The Consensus Article by Saeed et al (DOI: 10.1002/jor.24229) reports the findings of the 28-member Biofilm RW, which highlights 13 cutting-edge areas of MSKI and fundamental knowledge gaps in this field. The RW’s consensus spans conclusions on the molecular nature and function of biofilm, the mechanism by which biofilms resist antibiotics and host immunity, microbial synergizes in polymicrobial infections, diagnostics for biofilm on implants, definitions for minimum biofilm eradication concentration (MBEC) of anti-infective agents, and the potential of bacteriophage therapy. The Consensus Article by Schwarz et al (DOI:10.1002/jor.24293) presents the results of the 29-member General RW and has two salient features: up-to-date data on the current and projected incidences of infection, and costs per patient for all orthopaedic subspecialties, which range from 0.1%-30%, and $17,000-$150,000. The RW also reviewed all of the questions from ICM 2018 and determined that 23 of them are high priorities for research funding. These questions fall within six thematic categories: Acute vs. Chronic Infection, Host Immunity, Antibiotics, Diagnosis, Research Caveats, and Modifiable Factors.

To disseminate this information, the Journal of Orthopaedic Research established a new category of publication: Consensus Articles. These invited peer-reviewed manuscripts are submitted by a large group of recognized thought leaders who utilize an established methodology (e.g. the Delphi method) to derive a consensus on important issues based on established literature, non-peer reviewed information, and expert opinion. The resulting summary is intended to provide a broad audience guidance on the controversies and major unmet needs in the field, and to define the clinical and economic significance of the problems by providing consensus data on the incidences of the clinical problem, and costs. The Orthopaedic Research Society is supporting this effort by hosting free downloadable PDFs of the consensus questions, response, and rationale: Biofilm RW’s PDFs and General Assembly RW’s PDFs.  These high-impact Consensus Articles can positively influence multidisciplinary investigative teams with the will to solve these problems and private foundations, governmental agencies and commercial funding mechanisms who need to provide the medical community the resources necessary to establish best practices with scientific evidence.

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ICM document update: Ukrainian translation completed

ICM document Ukrainian translation completed and is available at the following link

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Paper of the week: Percutaneous CT guided bone biopsy for suspected osteomyelitis: Diagnostic yield and impact on patient’s treatment change and recovery.

Paper of the week: Percutaneous CT guided bone biopsy for suspected osteomyelitis: Diagnostic yield and impact on patient’s treatment change and recovery. Hoang D, Fisher S, Oz OK, La Fontaine J, Chhabra A. Eur J Radiol. 2019 May;114:85-91. doi: 10.1016/j.ejrad.2019.01.032.

Summary by Dr. Sreeram Penna

This retrospective audit was done to assess the utility of CT guided bone biopsy for suspected osteomyelitis. 115 patients were included in the study. Of these 40 patients had systemic symptoms of toxemia while 75 had only localized symptoms at the time of presentation. The most common bone biopsy site was the sacrum/ischium (49), followed by the spine (35), extremities (32), and the chest wall (2). Upon culture of the biopsy sample, only 24 were positive (21%). Of these positive cultures, 19 out of 24 have grown different organism compared to blood cultures. Common organism grown in biopsy cultures were Staphylococcus aureus (29.2%) followed by Escherichia coli (12.5%). Of the biopsies taken only 36 had histology performed. Of these 11 (30.6%) showed evidence of inflammation or osteomyelitis, 12 (33.3%) showed no evidence and 13 (38.1%) were inconclusive. In conclusion, this study shows a low yield of positive cultures or histology following bone biopsy for osteomyelitis.

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Paper of the week: Risk factors associated with periprosthetic joint infection after total elbow arthroplasty

Paper of the week: Risk factors associated with periprosthetic joint infection after total elbow arthroplasty. Somerson JS, Boylan MR, Hug KT, Naziri Q, Paulino CB, Huang JI. Shoulder Elbow. 2019 Apr;11(2):116-120. doi: 10.1177/1758573217741318.

Summary by Dr Sreeram Penna

This is a retrospective registry study of patients who had total elbow arthroplasty (TEA). Data was obtained from New York SPARCS database. Study included 1452 patients who had TEA in New York state between 1st Jan 2003 to 30th September 2012. Overall rate of infection was 3.72% (54/1452). There were 30 early infections (2.1%), 17 delayed infections (1.2%) and seven late infections (0.5%). Regression model showed that main risk factors associated with periprosthetic joint infection in TEA was rheumatoid arthritis (OR:3.31; p<0.001), tobacco use disorder (OR:3.39; p=0.003) and hypothyroidism (OR:2.04; p=0.045).