PhD Defense: Diagnostic challenges in Bone and Joint Infections; Lessons learned from international collaborations

Fracture-related infections (FRI) and periprosthetic joint infections (PJI) are serious complications in trauma and orthopedic surgery, resulting in high morbidity, loss of function, implant failure and even amputation. This thesis focuses on improving diagnosis and treatment of these diseases by analyzing current strategies and providing insight into patient characteristics.

Part I focuses on FRI. Serum inflammation markers have little diagnostic value and should mainly be used as suggestive criteria. Imaging using 18F-FDG PET/CT has 0.83 accuracy, but shows an increase in false negatives within one month postoperatively. Treatment of early FRI after debridement, antibiotics and implant-retention (DAIR) shows recurrence rate of 13.5% at 12 months.

Part II focuses on PJI. Serum and synovial markers for PJI in periprosthetic fractures are less accurate than in PJI alone. Higher cut-off values and combined markers should be used. Treatment of chronic culture-negative PJI using one-stage revision surgery shows comparable results to two-stage (re-infection 16.7% vs. 20.0% (p=0.69)). Revision surgery of infected internal fixation of peri-articular fractures shows higher recurrence rates than aseptic revision (35.0% vs. 11.3% (p=0.005), with more than one third due to mixed and resistant pathogens. PJI after knee and hip arthroplasties is the most common complication after re-revision (7.9% resp. 17.7%) and third revision surgery (10.0% resp. 17.4%). 

The dissertation concludes with a discussion in which the value of diagnosis and treatment for FRI and PJI is discussed and the lessons learned are described. In addition, recommendations are made for future research to improve care for trauma and orthopedic patients.