Diabetic foot infection is a frequent complication in long-standing diabetes mellitus. For antimicrobial therapy of this infection, both the optimal duration and the route of administration are often based more on expert opinion than on published evidence. We reviewed the scientific literature, specifically seeking prospective trials, and aimed at addressing two clinical issues: (1) shortening the currently recommended antibiotic duration and (2) using oral (rather than parenteral) therapy, especially after the patient has undergone debridement and revascularization. We also reviewed some older key articles that are critical to our understanding of the treatment of these infections, particularly with respect to diabetic foot osteomyelitis. Our conclusion is that the maximum duration of antibiotic therapy for osteomyelitis should be no more than to 4–6 weeks and might even be shorter in selected cases. In the future, in addition to conducting randomized trials and propagating national and international guidance, we should also explore innovative strategies, such as intraosseous antibiotic agents and bacteriophages.

Background: The skin commensal Cutibacterium avidum has been recognized as an emerging pathogen for periprosthetic joint infections (PJI). One currently assumes that the early occurring PJIs are a consequence of skin commensals contaminating the peri-implant tissue during surgery. We addressed whether standard skin antisepsis with povidone-iodine/alcohol before total hip arthroplasty (THA) is effective to eliminate colonizing bacteria with focus on C. avidum. Methods: In a single-center, prospective study, we screened all patients for skin colonizing C. avidum in the groin before THA. Only in the patients positive for C. avidum, we preoperatively repeated skin swabs after the first and third skin antisepsis and antibiotic prophylaxis. We also obtained dermis biopsies for microbiology and fluorescence in situ hybridization (FISH). Results: Fifty-one out of 60 patients (85%) were colonized on the skin with various bacteria, in particular with C. avidum in 12 out of 60. Skin antisepsis eliminated C. avidum in eight of ten (20%) colonized patients undergoing THA. Deeper skin (dermis) biopsies were all culture negative, but FISH detected single positive ribosome-rich C. avidum in one case near sweat glands. Conclusion: Standard skin antisepsis was not effective to completely eliminate colonizing C. avidum on the skin in the groin of patients undergoing THA. Colonizing with C. avidum might pose an increased risk for PJI when considering a THA. Novel more effective antisepsis strategies are needed. Trial registration No clinical trial

Introduction: Short stems are a bone and soft-tissue preserving alternative to conventional stems. The aim of this multicenter study is to present the mid-term outcomes of a calcar-guided short stem. Materials and methods: This is a prospective case series of the first 879 total hip arthroplasties performed on 782 patients across 5 centers using identical calcar-guided short stems. In a mid-term follow-up (6 years), rates and reasons for complications and revisions were documented. The Harris Hip Score (HHS) was obtained; patients reported pain and satisfaction using a visual analog scale. Results: A total of 43 patients died in the study cohort for non-related reasons; 26 patients (3.0%) required at least 1 revision after the index procedure. The survival rate for endpoint stem revision at mid-term was 98.4%. The main reasons for stem revision were aseptic loosening and early periprosthetic fractures. Sex had no influence on stem survival. Older patients or those with a high body mass index showed increased risk for stem revision during follow-up. Dorr type A morphology revealed a significantly lower risk of stem revision than Dorr type B or C (p = 0.0465). The HHS, satisfaction, and load pain at mid-term were 96.5 (SD 8.0), 9.7 (SD 0.9), and 0.5 (SD 1.9), respectively. Conclusions: This short stem produced highly satisfactory outcomes at mid-term, with 98.4% implant survival for any cause of stem revision and low complication rates. Long-term results are required to further evaluate these promising mid-term results.

Aims: Preprint servers allow authors to publish full-text manuscripts or interim findings prior to undergoing peer review. Several preprint servers have extended their services to biological sciences, clinical research, and medicine. The purpose of this study was to systematically identify and analyze all articles related to Trauma & Orthopaedic (T&O) surgery published in five medical preprint servers, and to investigate the factors that influence the subsequent rate of publication in a peer-reviewed journal. Methods: All preprints covering T&O surgery were systematically searched in five medical preprint servers (medRxiv, OSF Preprints, Preprints.org, PeerJ, and Research Square) and subsequently identified after a minimum of 12 months by searching for the title, keywords, and corresponding author in Google Scholar, PubMed, Scopus, Embase, Cochrane, and the Web of Science. Subsequent publication of a work was defined as publication in a peer-reviewed indexed journal. The rate of publication and time to peer-reviewed publication were assessed. Differences in definitive publication rates of preprints according to geographical origin and level of evidence were analyzed. Results: The number of preprints increased from 2014 to 2020 (p < 0.001). A total of 38.6% of the identified preprints (n = 331) were published in a peer-reviewed indexed journal after a mean time of 8.7 months (SD 5.4 (1 to 27)). The highest proportion of missing subsequent publications was in the preprints originating from Africa, Asia/Middle East, and South America, or in those that covered clinical research with a lower level of evidence (p < 0.001). Conclusion: Preprints are being published in increasing numbers in T&O surgery. Depending on the geographical origin and level of evidence, almost two-thirds of preprints are not subsequently published in a peer-reviewed indexed journal after one year. This raises major concerns regarding the dissemination and persistence of potentially wrong scientific work that bypasses peer review, and the orthopaedic community should discuss appropriate preventive measures. Cite this article: Bone Jt Open 2022;3(7):582–588.

Introduction: Empirical antibiotics should only target the most likely pathogens if antibiotic stewardship is being heeded. However, there is a drive for broader-spectrum empirical antibiotics in orthopedic infections due to the concern of therapeutic failure if a regimen fails to target subsequently identified pathogens. Methods: Retrospective case-control study with surgically managed orthopedic infections from July 2018 to June 2024 with a minimum follow-up of 6 months. Patients were stratified by the initial empirical treatment of either accurate empirical choice or inaccurate empirical choice. Results: Of 482 infection episodes, 79 antibiotic regimens (43 broad-spectrum; 9 %) were used with a median postoperative duration of 42 d (interquartile range 19–45 d); 290 infection episodes (60 %) were correctly targeted. In 192 cases (40 %), the initial empirical choice was inaccurate, with a median switching time to a targeted treatment of 4 d. There was no difference between accurate and inaccurate empirical treatment in terms of ultimate failures (18/290 vs. 15/192; Pearson χ² test, p=0.49), overall adverse events of therapy (15 % vs. 7 %, p=0.11), duration of hospital stay (median 9 d vs. 9 d, p=0.96), or supplementary surgical debridement (median 0 vs. 0 intervention, p=0.58). In multivariate logistic regression analysis, the duration of an inaccurate antibiotic treatment failed to alter the risk of “failures” (odds ratio 0.9, 95 % confidence interval 0.8–1.1). Conclusions: A delay in commencing targeted antibiotics does not increase the risk of a negative outcome. Narrower-spectrum empirical regimens are appropriate for clinically mild to moderate infections as a broader spectrum does not provide any clinical advantage.

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.