An investigation into the quality of life improvements after vertebral osteomyelitis depending on the status of pathogen detection.

OBJECTIVE: This study aimed to compare clinical characteristics and quality of life (QoL) after vertebral osteomyelitis (VO) based on the status of pathogen detection in microbiological sampling. METHODS: We conducted a post hoc data analysis from a prospective single-center study in a tertiary referral hospital, including VO patients from 2008 to 2020. Data were collected preoperatively (T0) and 1-year post surgery (T1). The primary outcome was QoL, assessed with the Oswestry Disability Index and Core Outcome Measures Index. RESULTS: Data from 133 patients with surgically treated thoracic or lumbar VO were evaluated. The pathogen was detected from cultured intraoperative samples in 100 (75.2%) patients (group 1). Culture remained negative in 33 (24.8%) patients (group 2). Quality of life did not differ significantly between the groups at T1. We observed higher preoperative C-reactive protein values and higher rates of spinal empyema at T0 in group 1. CONCLUSION: Quality of life improved significantly for all patients at T1, but scores remained comparable to those reported by patients with chronic back pain. Quality of life was not affected by pathogen detection. However, attempts to detect pathogens are still indicated due to the concomitant findings, including bacteremia and epidural abscesses, along with the advantages of targeted antibiotic therapy. The most critical step for detection may be avoiding pre-sampling antibiotic administration. Cite this article as: Beyer F, Wenk B, Jung N, Bredow J, Eysel P, Yagdiran A. An investigation into quality of life improvements after vertebral osteomyelitis depending on the status of pathogen detection. Acta Orthop Traumatol Turc., 2024; 10.5152/j.aott.2024.23073 [Epub Ahead of Print].

Detection of Cutibacterium (Propionibacterium) acnes in orthopaedic surgery: serious problem or contamination?

PURPOSE: Bone and joint infections are an important and increasing problem. Whether intraoperatively detected bacteria should be considered relevant or not is often difficult to assess. This retrospective cohort study analyzes the relevance of C. acnes cultured from deep intraoperative specimens. METHODS: All deep tissue samples collected intraoperatively between 2015 and 2020 from a quartiary care provider were evaluated for detection of C. acnes and its therapeutical consequences. Infection rates were determined according to a standardized definition and protocol and analyzed in dependence of patient's demographic data (age and gender), operative parameters (type of surgery, body region/location of surgery, and impression of the surgeon), and initiated therapy. RESULTS: In 270 cases of more than 8500 samples, C. acnes was detected. In 30%, the detection was considered an infection. The number of samples taken and tested positive for C. acnes correlated significantly with its classification as a cause of infection. If more than one sample of the patient was positive, the detection was significantly more likely to be treated as infection (p < 0.001). In 76% of cases, a consultation to the infectious diseases (ID) department took place regarding the classification of the pathogen detection and the therapy to be carried out. Almost all of the tested isolates demonstrated the wild-type susceptibility for penicillin and clindamycin. CONCLUSION: Intraoperative detection of skin-colonizing bacteria such as C. acnes is not always synonymous with infection. In particular, if other examination results contradict an infection (pathological sample without evidence of an infectious event, detection of malignant cells, etc.), the situation must be considered in a very differentiated manner. Interdisciplinary boards, for example, are suitable for this purpose. Care should be taken to obtain a sufficiently large number of tissue samples for microbiological examination to be able to better classify the result.

Surgery for Vertebral Osteomyelitis Lowers 1-Year Mortality and Failure Rates Compared with Nonsurgical Treatment: A Propensity-Matched Analysis.

BACKGROUND: The aim of this study was to determine differences between patients who underwent surgical treatment and those who underwent nonsurgical treatment of vertebral osteomyelitis (VO) and to identify potential factors influencing treatment failure (death and/or recurrence within 1 year). METHODS: We performed a retrospective analysis of clinical data prospectively collected from patients treated for VO between 2008 and 2020. The decision between surgical and nonsurgical treatment was made for each patient based on defined criteria. A 1:1 propensity score matching was performed to exclude confounders between the 2 treatments. Univariate and multivariable analyses were performed to identify potential risk factors for death and/or recurrence within the first year after VO diagnosis. RESULTS: Forty-two patients (11.8%) were treated nonsurgically and 313 patients (88.2%) underwent surgery. A higher percentage of the surgically treated patients than the nonsurgically treated patients had an American Society of Anesthesiologists score of >2 (69.0% versus 47.5%; p = 0.007), and the thoracic spine was affected more often in the surgical group (30.4% versus 11.9%; p = 0.013). Endocarditis was detected significantly more often in the nonsurgically treated patients (14.3% versus 4.2%; p = 0.018). The recurrence rate was 3 times higher in the nonsurgically treated patients (16.7% versus 5.4%; p = 0.017), but this difference was no longer detectable after propensity matching. After matching, the nonsurgically treated patients showed an almost 7-fold higher 1-year mortality rate (25.0% versus 3.7%; p = 0.018) and an almost 3-fold higher rate of treatment failure (42.9% versus 14.8%; p = 0.022). Multivariable analysis revealed nonsurgical treatment and bacteremia to be independent risk factors for treatment failure. CONCLUSIONS: In our matched cohort of patients with VO, surgical intervention resulted in a significantly lower rate of treatment failure (death and/or recurrence within 1 year) compared with nonsurgical intervention. Furthermore, nonsurgical treatment was an independent risk factor for treatment failure. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Quality of Life with Respect to Surgically Treated Vertebral Osteomyelitis and Degenerative Spondylolisthesis. / Vergleich der Lebensqualität nach operativer Therapie einer vertebralen Osteomyelitis und degenerativer Spondylolisthesis.

Vertebral osteomyelitis (VO) and degenerative spondylolisthesis (SL) are 2 commonly treated spinal conditions. Therefore, in the presented work, the quality of life after surgical therapy of these 2 entities is compared using established scores.In a monocentric study, all patients with VO and SL were prospectively enrolled using the Spine Tango Registry. Surgical procedures included one- or two-stage fusion of the affected segments. Quality of life was assessed using the Core Outcome Measures Index (COMI) and the Oswestry Disability Index (ODI) at time points t0 (0 months), t1 (12 months), and t2 (24 months). Statistical analysis was performed using SPSS. The level of significance was set at 5%.52 patients with VO and 48 patients with SL were included in the analysis. There were no significant differences in age and gender distribution. The length of stay in the SL group was significantly shorter (p < 0.001). ODI at time t0 was significantly higher in the VO group (p < 0.001), whereas COMI scores did not differ significantly (p = 0.155). At time points t1 and t2, the differences between the VO and SL groups were not significantly different for either the ODI score (p = 0.176; p = 0.250) or the COMI score (p = 0.682; p = 0.640).Postoperative quality of life scores after lumbar fusion surgery in SL and VO are comparable despite different indications and medical conditions. In both groups, similar quality of life with in patient with chronic back pain was achieved. This should be considered for the preoperative assessment, as well as for the indication for surgery in SL.

Risk Factors for Neurologic Deficits in Patients With Spinal Epidural Abscess: An Analysis of One-Hundred-Forty Cases.

STUDY DESIGN: retrospective study. OBJECTIVES: In addition to surgical treatment of spinal epidural abscesses (SEA), a conservative, medical treatment for patients without acute neurologic deficits has been proposed. However, the risk factors for neurologic deficits are unclear. This study aims to identify factors predisposing patients with SEA to neurological impairment. METHODS: All patients treated for SEA between 2008 and 2021 were identified from a prospective vertebral-osteomyelitis registry of a tertiary referral centre. Patient demographics, comorbidities, pathogens, degree of osseous destruction, location of SEA and preoperative neurologic status were retrospectively collected. Differences between patients with (Group 1) and without (Group 2) pretreatment neurologic deficits were assessed by univariate and logistic regression analysis. RESULTS: A total of 140 patients with SEA were included. Forty-three patients (31%) had a neurologic deficit and 97 patients (69%) had no neurologic deficit prior to therapy. The prevalence of diabetes mellitus (35% vs 19%, P = .03), median visual analogue scale leg pain (8 vs 5, P = .01), median American Society of Anesthesiologists (ASA) Score (3 vs 2.6, P = .003) and mean Body-Mass-Index (29 vs 26, P = .02) differed between Group 1 and 2 in univariate analysis. In multivariable analysis, diabetes mellitus (odds ratio = 2.7), female sex (odds ratio = 2.5) and ASA-Score (odds ratio = 2.4) were significant contributors for neurologic deficits. CONCLUSIONS: In patients with a SEA without neurologic deficits, the ASA score and diabetes mellitus should be considered, especially in female patients. These patients may be at a higher risk for developing a neurologic deficit and may benefit from an early surgical treatment.

Determining threshold values for success after surgical treatment of lumbar spondylodiscitis using quality of life scores.

OBJECTIVE: This study aimed to determine threshold values of validated quality of life (QoL) scores, including Oswestry Disability Index (ODI) and Core Outcome Measures Index (COMI), for predicting a successful outcome following surgical treatment of lumbar spondylodiscitis (LS). METHODS: Patients with lumbar spondylodiscitis (LS) undergoing surgery in a tertiary referral hospital were included prospectively from 2008-2019. Data were collected both before surgery (T0) and one year after surgery (T1). QoL was measured using ODI and COMI. The successful clinical outcome was defined by the combination of the following four criteria: no recurrence of spondylodiscitis, back pain ≤4 on visual analogue scale or relief of ≥3 points, absence of LS-related neurological deficit, and radiological fusion of the affected segment. For subgroup analysis, group 1 consisted of patients with a favorable treatment outcome (meeting all four criteria), while group 2 included patients with unfavorable treatment outcome (meeting ≤3 criteria). RESULTS: Ninety-two LS patients (median age = 66 years; age range = 57-74) were analyzed. QoL scores improved significantly. Threshold values for the ODI and COMI were calculated at 35 and 4.2 points, respectively. The area under curve for the ODI was 0.856 (95%-CI 0.767- 0.945; P<0.001) and 0.839 (95% CI-0.749-0.928; P<0.001) for the COMI score. Eighty percent of patients achieved a favorable outcome. CONCLUSION: Objective measurement and evaluation of successful surgical treatment of spondylodiscitis require defined thresholds of quality of life scores. We were able to define such thresholds for Oswestry Disability Index and Core Outcome Measures Index. These can be useful to assess clinically relevant changes and therefore allow a more precise estimation of the post-surgical outcome. LEVEL OF EVIDENCE: Level II, Prognostic study.

Can triclosan-coated sutures reduce the postoperative rate of wound infection? Data from a systematic review and meta-analysis.

BACKGROUND: Wound infections are typical postoperative complications with considerable therapeutic consequences and high personnel and financial costs. Previous meta-analyses have shown that triclosan-coated sutures can reduce the risk of postoperative wound infection. This work aimed to update previous meta-analyses with a special focus on different subgroups. METHODS: A systematic review with meta-analysis was performed (registration: PROSPERO 2022 CRD42022344194). The search was independently performed in the Web of Science, PubMed, and Cochrane databases by 2 reviewers. A critical methods review of all included full texts took place. The trustworthiness of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation method. An analysis of the cost-effectiveness of the suture material was carried out. RESULTS: In this meta-analysis of 29 randomized controlled trials, the use of triclosan-coated suture material resulted in a significant reduction of postoperative wound infection rate (24%) (random-effects model; risk ratio: 0.76; 95% confidence interval: [0.67-0.87]). The effect was evident in the subgroups according to wound contamination class, underlying oncologic disease, and pure preoperative antibiotic prophylaxis. In the subgroup analysis by the operating department, the significant effect was visible only in the abdominal surgery group. CONCLUSION: Based on the randomized controlled clinical trials reviewed, triclosan-coated sutures reduced postoperative wound infection rates in the main study and most subgroups. Additional costs of up to 12 euros for the coated suture material appear to be justified to generate an economic benefit for the hospital by reducing postoperative wound infections. The additional socioeconomic benefit of reducing wound infection rates was not investigated here.

Clinical features and outcome of vertebral osteomyelitis after spinal injection: is it worth the price?

PURPOSE: Spinal injections are increasingly used for back pain treatment. Vertebral osteomyelitis (VO) after spinal injection (SIVO) is rare, but patient characteristics and outcome have not been well characterized. The aim of this study was to assess patient characteristics of SIVO in comparison to patients with native vertebral osteomyelitis (NVO) and to determine predictors for 1-year survival. METHODS: This is a single-center cohort study from a tertiary referral hospital. This is a retrospective analysis of Patients with VO who were prospectively enrolled into a spine registry from 2008 to 2019. Student's t-test, Kruskal-Wallis test or Chi-square test were applied for group comparisons. Survival analysis was performed using a log-rank test and a multivariable Cox regression model. RESULTS: 283 VO patients were enrolled in the study, of whom 44 (15.5%) had SIVO and 239 (84.5%) NVO. Patients with SIVO were significantly younger, had a lower Charlson comorbidity index and a shorter hospital stay compared to NVO. They also showed a higher rate of psoas abscesses and spinal empyema (38.6% [SIVO] vs. 20.9% [NVO]). Staphylococcus aureus (27%) and coagulase-negative staphylococci (CNS) (25%) were equally often detected in SIVO while S. aureus was more frequently than CNS in NVO (38.1% vs. 7.9%).Patients with SIVO (P = 0.04) had a higher 1-year survival rate (Fig. 1). After multivariate analysis, ASA score was associated with a lower 1-year survival in VO. CONCLUSION: The results from this study emphasize unique clinical features of SIVO, which warrant that SIVO should be estimated as a separate entity of VO.

Evaluation of Classification Systems and Their Correlation With Clinical and Quality-of-life Parameters in Patients With Surgically Treated Spondylodiskitis.

INTRODUCTION: Surgical classifications for spondylodiscitis (SD) typically include radiologic features and the status of neurologic impairment. Clinical factors such as preoperative pain, function/disability, overall quality of life (QoL), and risk of recurrence and mortality, which are necessary for a comprehensive assessment of SD and measurement of treatment success, are not considered. There is a lack of external validation of SD classifications. The aim of this study was to validate classifications of SD and to correlate these classifications with the above clinical factors. METHODS: One hundred fourteen patients from a prospective SD register (2008-2020) with available imaging, preoperative neurologic status, backpain, function/disability data (Oswestry Disability Index and Core Outcome Measures Index), QoL data (Short Form 36, European Quality-of-life Questionnaire), and a 1-year follow-up were retrospectively classified according to Akbar, Homagk, and Pola classifications. Interrater reliability, correlation among classifications, and correlation between classifications and QoL were calculated. RESULTS: Interrater reliability was κ = 0.83 for Akbar, κ = 0.94 for Homagk, and κ = 0.99 for Pola. The correlation of Akbar with Pola and Homagk was moderate (ρ s = 0.47; ρ s = 0.46) and high between Pola and Homagk (ρ s = 0.7). No notable correlation was observed between any of the classifications and preoperative Oswestry Disability Index, Core Outcome Measures Index, QoL, mortality, and recurrence within 1 year. Only a weak correlation was observed between Homagk and preoperative leg pain and back pain. CONCLUSION: Available SD classifications have a very good interrater reliability and moderate-to-high correlation with each other but lack correlation with preoperative pain, function/disability, and overall QoL. Because these factors are important for a comprehensive assessment of SD in severity, decision making, and prognosis, they should be included in future SD classifications. This could allow for more comprehensive treatment algorithms. LEVEL OF EVIDENCE: Level II. Diagnostic study = prospective cohort study; development of diagnostic criteria. DATA AVAILABILITY: The data sets used and analyzed during this study are available from the corresponding author on reasonable request.

Impact of a pediatric infectious disease consultation service on timely step-down to oral antibiotic treatment for bone and joint infections.

PURPOSE: In recent years an earlier step down to oral antibiotic therapy has been advocated for numerous infections. Trained infectious disease specialists regularly consulting their colleagues may speed up the implementation of such recommendations into clinical practice and thus may improve treatment. METHODS: We retrospectively analyzed bone and joint infections in children admitted to the University Hospital of Cologne between 2010 and 2021. We assessed clinical, imaging, and microbiological findings and treatment modalities. Additionally, we assessed both the impact of a newly implemented pediatric infectious diseases consultation service and publications on revised treatment recommendations by comparing antibiotic therapy in two periods (2010-2016 versus 2017 to 2021). RESULTS: In total, 29 children presented with osteomyelitis, 16 with bacterial arthritis and 7 with discitis. In period 2 (2017-2021) we observed shorter duration of intravenous treatment (p = 0.009) and a higher percentage of oral antibiotic treatment in relation to the total duration of antibiotics (25% versus 59%, p = 0.007) compared to period 1 (2010-2016). Yet, no differences were identified for the total length of antibiotic treatment. Additionally, biopsies or synovial fluid samples were retrieved and cultured in more children in period 2 (p = 0.077). The main pathogen identified in osteomyelitis and bacterial arthritis was Staphylococcus aureus (MSSA), diagnosis was confirmed predominantly with MRI. CONCLUSION: Recent guidelines addressing the safety of an earlier step-down (to oral) antibiotic therapy have influenced clinical practice in the treatment of bone and joint infections in our hospital. A newly implemented pediatric infectious diseases consultation service might have accelerated this progress resulting in a faster step down to oral treatment.

Four decades of developmental dysplastic hip screening according to Graf: What have we learned?

Purpose: Sonographic hip examination according to Graf is widely accepted standard for diagnosing developmental dysplastic hips (DDH) but it is criticized for alleged intra- and interobserver variations. This review was conducted to evaluate whether objective quality criteria according to the Graf method are fulfilled within scientific literature. Methods: A systematic literature search on Pubmed was performed using the search string: [(DDH) OR (Hip dysplasia)] AND (Graf). Studies suitable by title, abstract, manuscript, containing an image of sonographic hip examination and online accessibility were included into analysis. Results: 131 studies were included into final analysis. Only 68 (51.9%) presented correct sonographic images according Graf's criteria. 98 (74.8%) studies plotted alpha-angles (angle between bony roof line and base line) but only 85 (64.8%) studies beta-angles (angle between cartilage roof line and base line). Studies were contributed from 25 countries. Conclusion: Assumingly, skepticism regarding the Graf method is based on user errors and insufficient application of the Graf quality assessment algorithm resulting in high intra- and interobserver variations. When performed correctly, the Graf method is of high diagnostic value.

The influence of orthopedic surgery on the incidence of post-operative delirium in geriatric patients: results of a prospective observational study.

Background: Postoperative delirium (PD) is a major concern in geriatric patients undergoing orthopedic surgery. This prospective observational study aims to examine the incidence of PD, to identify intervention-specific risk factors and to investigate the influence of orthopedic surgery on delirium. Methods: From 2019 to 2020, 132 patients ≥70 years of age with endoprosthetic (Group E) or spinal surgery (Group S) were included. Upon admission, the ISAR score, the Nursing Delirium Screening Scale, potential risk factors, the ASA score, duration of surgery, type of anesthesia, blood loss, and hemoglobin drop were recorded. For risk factor analysis patients were grouped into Group D (delirium) and Group ND (no delirium). Primary endpoint was the occurrence of PD. Results: Of 132 patients, 50 were included in Group E and 82 in Group S. Mean age and ISAR score were not significantly different between groups. Delirium rate in Group E and S was 12% vs. 18% (p = 0.3). Differences could be observed between Group D and ND in duration of surgery (173 min vs. 112 min, p = 0.02), postoperative hemoglobin drop (3.2 g/dl vs. 2.3 g/dl; p = 0.026), history of PD (23% vs. 11%, p = 0.039) and use of isoflurane (6 vs. 2). Type of surgery was not an independent risk factor (p = 0.26). Conclusion: Specific type of orthopedic surgery is not an independent risk factor for PD. Prevention of PD should focus on duration of surgery and blood loss, particularly in patients with a history of PD. A possible delirogenic potential of isoflurane should be further studied.

What Do We Know about Spondylodiscitis in Children? A Retrospective Study.

Pediatric spondylodiscitis (PSD) is a rare disease with a major impact on mobility and functional status. Data concerning demographic and microbiological characteristics, clinical course, treatment, and outcome are scarce. Therefore, the aim of this study was to present clinical experiences of a third-level hospital (2009-2019) in PSD and compare these with adult spondylodiscitis (ASD). Of a total of 10 PSD patients, most of the infants presented with unspecific pain such as hip pain or a limping, misleading an adequate diagnosis of spine origin. Eight patients could be treated conservatively whereas surgery was performed in two cases with one case of tuberculous PSD (tPSD). The causative agent was detected in three of the patients. The diagnosis of PSD is often difficult since clinical symptoms are unspecific and causative pathogens often remain undetected. Nevertheless, empirical anti-infective therapy also seems to be effective. Based on recent studies, clinicians should be encouraged to keep the duration of anti-infective therapy in children short. Since comorbidities are not presented in PSD it is unclear which children suffer from PSD; thus, studies are necessary to identify predisposing factors for PSD. In our study, PSD differs from ASD in diagnostic and especially in therapeutic aspects. Therefore, specific guidelines for PSD would be desirable.

Treatment Failure in Vertebral Osteomyelitis: Is it All About Staphylococcus aureus ?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim was to compare the influence of 2 common vertebral osteomyelitis (VO) causing pathogens on treatment failure within the first year of diagnosis. SUMMARY OF BACKGROUND DATA: VO is mainly caused by Staphylococcus aureus (SA), while enterococci and streptococci (ENST) are also responsible for a significant proportion of VO, particularly in elderly patients. Data on VO caused by SA show a tendency for worse outcome, whereas data on VO caused by ENST are scarce. For this purpose, our study compares characteristics of patients with VO caused by SA or ENST in order to analyze risk factors for treatment failure. METHODS: We conducted a retrospective monocentric study including VO patients from 2008 to 2020. Primary outcome was treatment failure defined as death or relapse within 1 year (T1). We compared patients diagnosed with VO caused by Staphylococcus aureus including MRSA to patients diagnosed with VO caused by Enterococcus and Streptococcus species, which were combined into one group. Polymicrobial infections were excluded. We employed multiple logistic regression analysis to adjust for confounding. To account for moderation, the model was repeated with an included interaction term. RESULTS: Data of 130 VO patients (SA=95; ENST=35) were available at T1. Treatment failure occurred in 37% of SA patients and 23% of ENST patients. On multivariate analysis SA [odds ratio (OR): 3.12; 95% confidence interval (CI): 1.09-10.53; P =0.046], Charlson comorbidity index (OR: 1.31; 95% CI: 1.11-1.58; P =0.002) and infectious endocarditis (IE; OR: 4.29; 95% CI: 1.23-15.96; P =0.024) were identified as independent risk factors for treatment failure. CONCLUSION: In our cohort every third patient with VO caused by SA or ENST dies within 1 year. Our findings indicate that patients with VO caused by SA, concomitant IE and/or a high Charlson comorbidity index score may be at elevated risk for treatment failure. These findings can be used to individualize patient care and to direct clinical surveillance. This could include echocardiography evaluating for the presence of IE in patients with VO caused by gram-positive pathogens.

The Burden of Vertebral Osteomyelitis-An Analysis of the Workforce before and after Treatment.

Although vertebral osteomyelitis (VO) has a major impact on morbidity, functional status, and quality of life, data concerning the influence on the patient's ability to work (ATW) are lacking. Therefore, the aim of this study was to analyze the work status after VO-treatment as well as risk factors associated with loss of the ATW. We conducted a post-hoc analysis of data from a prospective VO-registry (2008-2019) supplemented by workforce data. Primary endpoint was the work status after one year (T1). Univariate analysis comparing patients' characteristics "at-work" versus "not-at-work" at T1 was performed. Of a total of 335 VO-patients, n = 52 (16%) were part of the workforce at time of diagnosis (T0), of which 22 (42%) failed to be part of the workforce at T1. A higher number of comorbidities and a body mass index (BMI) < 25 kg/m2 were associated with a reduced ATW. VO in working age patients is a debilitating condition and associated with reduced patients' ATW. Patients engaged in heavy physical work mostly had a BMI < 25 kg/m2 and therefore were more severely affected and no longer able to keep their workforce. More support in retraining should be offered after successful treatment to maintain ATW and reduce the socio-economic burden.

Alveolar echinococcosis as a cause of vertebral osteomyelitis and soft tissue infection with recurrent cutaneous fistula formation.

Echinococcus multilocularis is endemic in Germany. However, alveolar echinococcosis is a rare disease. Most commonly the parasite affects the liver, behaving like a malignant tumour. Bones are affected in less than 2% of cases. We report a case of vertebral osteomyelitis accompanied by recurrent cutaneous fistula formation.

The diagnostic value of cytokines for the discrimination of vertebral osteomyelitis and degenerative diseases of the spine.

Vertebral osteomyelitis (VO) is a primary infection of the endplates of the vertebral bodies with secondary infection of the adjacent intervertebral discs. Diagnosis is often delayed due to unspecific symptoms and a lack of specific infection markers. In this prospective study, we determined the suitability of 27 cytokines for the discrimination of VO and degenerative diseases of the spine and compared its diagnostic potential in relation to the C-reactive protein (CRP), which is widely used as a non-specific inflammation marker in clinical diagnostics. The patients included in this study underwent surgical stabilization of the lumbar and/or thoracic spine with removal of 1 or more affected intervertebral discs, as therapy for VO (n = 16) or for erosive osteochondrosis (EO, control group, n = 20). We evaluated the cytokine and CRP concentrations before (pre-OP = -20-0d where 0 means the day of surgery) and after surgery (post-OP) on days 3-5, 6-11, 40-56, and 63-142. Compared to the control patients pre-OP, a significantly higher elevation of the 4 cytokines IL-6, IL-8, IL-12 (p70), and VEGF as well as CRP were found in the VO patients, showing an area under the curve > 0.80 pre-OP. No significant differences were observed between VO patients with high and low virulent bacteria with respect to all 5 elevated biomarkers. This is the first prospective study in which a broad spectrum of 27 cytokines was analysed via multiplex assay using sera from patients with and without VO. Our results show that, in addition to CRP, 4 different cytokines were significantly altered in VO but not control patients. The results implicate that these candidate cytokines may be used in a multiplex assay for discrimination between VO and degenerative diseases of the spine.

Establishment of an interdisciplinary board for bone and joint infections.

PURPOSE: The incidence of bone and joint infections is increasing while their treatment remains a challenge. Although guidelines and recommendations exist, evidence is often lacking and treatment complicated by complex clinical presentations and therapeutic options. Interdisciplinary boards shown to improve management of other diseases, seem potentially helpful. We describe the establishment of an osteomyelitis board to show the existing demand for such a platform. METHODS: All patients discussed in the board for bone and joint infections between October 2014 and September 2020 were included in this retrospective study. Data were extracted from patient records and analyzed descriptively. RESULTS: A total of 851 requests related to 563 patients were discussed in the board during the study period. After a run-in period of 3 years, a stable number of cases (> 170/year) were discussed, submitted by nearly all hospital departments (22 of 25). Recommendations were mainly related to antibiotic treatment (43%) and to diagnostics (24%). Periprosthetic joint infections were the most frequent entity (33%), followed by native vertebral osteomyelitis and other osteomyelitis. In 3% of requests, suspected infection could be excluded, in 7% further diagnostics were recommended to confirm or rule out infection. CONCLUSIONS: A multidisciplinary board for bone and joint infections was successfully established, potentially serving as a template for further boards. Recommendations were mainly related to antibiotic treatment and further diagnostics, highlighting the need for interdisciplinary discussion to individualize and optimize treatment plans based on guidelines. Further research in needed to evaluate impact on morbidity, mortality and costs.

Periprosthetic infections: How do we diagnose and treat? Results of an online survey and comparison with international recommendations.

OBJECTIVE: Endoprosthetic replacement surgery of hip and knee joints is widely performed, but always carries the risk of developing periprosthetic infection (PPI). Treatment of PPI is lengthy and demanding for the patient, often involving multiple surgeries as well as lengthy drug therapies. Remediation is not always successful despite extensive therapy. METHODS: An online survey was used to investigate whether the therapeutic measures implemented in German hospitals are based on international treatment recommendations. For this purpose, German physicians who regularly treat periprosthetic infections in their clinics were asked to complete an online questionnaire. The questionnaire asked about internal hospital procedures. These were then compared with international recommendations. RESULTS: With a response rate of 10.9%, the questionnaire shows agreement with the international recommendations in large parts of the operative and medicinal procedures. In preoperative imaging for example, two-plane radiographs are the standard. Similarly, the participants' approach to preoperative specimen collection, incubation time, and operative management (regarding one- or two-stage approach to septic joint) reflects the recommendations. Deviations were particularly evident in the area of laboratory diagnostics, where the erythrocyte sedimentation rate (ESR) is determined in only 17.1%, contrary to the recommendations. Whereas procalcitonin (PCT) and blood culture sampling takes place regularly. Clear differences emerges in the use of drains, which, contrary to the recommendations, are used very regularly (almost 70%). In this survey, the time intervals between the onset of infection symptoms and the start of therapy (prosthesis-preserving therapy) is shown to be longer than recommended internationally. CONCLUSION: In summary, however, the recommended approaches of the international groups in most respects are followed, a high willingness of respondents to collaborate with local infectious disease specialists demonstrates the complexity of the disease.

Quality of life and mortality after surgical treatment for vertebral osteomyelitis (VO): a prospective study.

PURPOSE: Vertebral osteomyelitis (VO) has a high mortality and leads to chronic pain and functional disability. Surgical treatment is often necessary. To date, little is known about the consequences of surgery on patient outcome. The aim of this study was to determine the quality of life (QoL) and mortality rates of surgically treated VO patients for a period of 2 years. METHODS: Patients with VO undergoing surgical treatment in a tertiary referral hospital from 2008 to 2015 were included prospectively. Data were collected before (T0) as well as 1 year (T1) and 2 years (T2) post-surgery. Within the European Spine Tango registry, prospective patient and QoL data were collected using validated outcome scores: Oswestry Disability Index, Short Form 36/EuroQol, Visual Analog Scale, and Core Outcome Measures Index. RESULTS: From 195 patients surgically treated for VO, QoL data were available from 136 patients at T0, 100 patients at T1, and 82 patients at T2, respectively. The 1- and 2-year mortality rates were 20% and 23%. Mainly all QoL outcome scores showed significant improvement at T1 and did not change significantly from T1 to T2. CONCLUSION: Surgical treatment of VO patients leads to significantly improved QoL. Nevertheless, QoL levels were below those of the general population. Our results underscore that spine disability questionnaires measuring QoL are mandatory to demonstrate comprehensively the severity of this entity. Our study confirms a high mortality and points out the role of VO as a potentially life-threatening condition.