Infection & Inflammation

Spondylodiscitis and vertebral osteomyelitis: pyogenic, tuberculous, and fungal etiologies with a focus on pathogen identification and morbidity risk.

Overview

Postoperative infection remains a critical complication across orthopaedic procedures, ranging from local myofascitis of the deltoid following vaccination [2] to serious wound complications after total elbow arthroplasty with an incidence of 5.5% [23]. Approximately 25% of these serious wound complications progress to sepsis, and roughly half of those cases necessitate implant removal [23]. Consecutive fevers or temperatures ≥39 °C after total joint arthroplasty may indicate postoperative infection, mandating immediate testing to rule out infectious etiologies [39].

Management strategies depend heavily on the specific pathogen and chronicity of the disease. For spondylodiscitis, favorable outcomes correlate with normalized CRP levels and antibiotic therapy exceeding 6 weeks, whereas concomitant infections predict unfavorable results [4]. In contrast, no specific tests currently guide the cessation of antimicrobial agents, as ESR and CRP often remain elevated post-eradication [10]. Chronic infections represent an absolute contraindication for debridement with implant retention due to mature biofilm formation, while acute cases require urgent debridement after medical optimization [18]. Selection for retention requires a nuanced understanding of host, procedural, and pathogen variables [15].

Specific pathogens demand tailored approaches; nontuberculous mycobacterium infections should be suspected in persistent hand inflammation, treated initially with macrolide and ethambutol pending sensitivity results [22]. Kocuria species outcomes vary by infection type, with higher success rates in infective endocarditis [8]. While acute hand infections require incision, drainage, and organism-tailored antibiotics [24], shoulder periprosthetic joint infection outcomes do not differ from those revised for noninfectious indications [20]. Establishing a consensus definition for periprosthetic shoulder infection remains critical for future investigations [21].

Anatomy & Pathophysiology

Osseous

Spinal infections can cause mechanical instability and possible neurologic compromise when left untreated [89]. The spinal fixation mechanical failure rate after tumor resection is 10% [90]. Anatomical variations in the apophyseal articular processes between the second and third cervical vertebrae are frequent and may produce irregular motion and joint instability, potentially contributing to headaches and nerve irritation [93]. Correction of deformity at an early age is important [94]. Preoperative planning to accurately select and insert pedicle screws in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree [95]. If the diagnosis and treatment of spinal tuberculosis are delayed, spinal damage and other consequences might be incurable [102].

Ligamentous & Joint Stability

Charcot arthropathy of the spine is a progressive disorder involving a destructive process of the anatomical elements which provide spinal stability, often with delayed clinical recognition [81]. Posterior and posterior superior labral injuries produce alterations in glenohumeral kinematics with implications for glenohumeral joint instability, increased glenohumeral joint loading, and potential joint damage [83].

Kinetics & Matrix Response

Mechanical loading plays an important role for cellular and matrix responses in tendon [86].

Cement & Structural Integrity

The rate of bone cement leakage into the thoracic spinal canal is significantly higher than that into the lumbar spinal canal due to differences in thoracic and lumbar posterior vertebral wall morphology [91].

Classification

Periprosthetic Joint Infection (PJI): A universal definition for PJI has been proposed to standardize diagnosis and facilitate comparison of published evidence [74], while a new definition serves as a 'gold standard' for universal adoption by clinicians, surveillance authorities, and researchers [76]. However, no evidence-based time interval divides acute from chronic PJI, as the natural history of infection is a continuum from initiation to chronicity [11]. Distinct differences exist between PJI classifications for the shoulder, warranting further investigation to determine accurate diagnosis and optimal treatment [65], and a consensus definition for periprosthetic shoulder infection is critical for future investigations of these complications [21].

Shoulder Septic Arthritis: A novel MRI-based classification system stratifies septic arthritis of the shoulder into grades, where patients with Grade III or higher classifications exhibit higher reinfection rates than those with Grade I or II classifications [49]. These Grade III or higher cases require more aggressive treatment to eradicate the infection [49]. Additionally, a comprehensive system for the classification and management of spontaneous shoulder sepsis has been proposed based on stage and anatomy [64], with preoperative MRI aiding in determining disease severity and surgical decision-making for this condition [64].

Hand Infections: Hand infections include a diverse array of entities with potential for serious morbidity [77]. Chronic hand infections are uncommon and require a high index of suspicion for early diagnosis [78]. These chronic infections are grouped by microorganism into bacterial (mycobacterial and others), fungal, and viral types [78].

Other Considerations: Infection outcomes for Kocuria species vary by infection type, with higher mortality observed in infective endocarditis [8]. Narrowing of the intervertebral-disc space in children is presumed to be an infectious lesion, potentially triggered by trauma in the presence of transient bacteremia [9]. Risk stratification tools have been developed to predict the likelihood of septic arthritis in both immunocompetent and immunocompromised patients [79]. Adhering to strict diagnostic and treatment algorithms while utilizing new classifications and scoring systems can predict patient outcomes and improve care and resource utilization in pediatric musculoskeletal infections [62]. Regarding Cutibacterium acnes, evidence supports conceptualizing it as a common commensal and frequent contaminant in shoulder surgery studies [82], yet it is also an uncommon cause of an inflammatory host response [82].

Clinical Presentation

Early and accurate diagnosis of infectious spondylitis is critical for preventing long-term complications [1]. In pediatric populations, the etiology of narrowing of the intervertebral-disc space is very likely infectious, where trauma in the presence of transient bacteremia may play a role in pathogenesis [9]. Diagnosis of spinal tuberculosis in the early inflammatory stage is essential to prevent deformity and neurological deficit [34]. Conversely, in the absence of abnormal clinical signs and symptoms, postoperative leukocytosis may not warrant further workup for infection after total hip and knee arthroplasty [35].

Persistent symptoms following AstraZeneca (AZD1222) COVID-19 vaccine administration may indicate local myofascitis, requiring consideration of infection, blood tests, imaging, and empirical antibiotics [2]. Infectious causes should be considered in the workup of patients presenting with common signs and symptoms who do not respond to initial nonoperative treatment [5]. Septic arthritis in rheumatoid arthritis patients is difficult to identify and requires a high degree of clinical suspicion; early diagnosis is crucial to prevent disastrous sequelae [33]. Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms [32]. Early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism in atypical hand infections [32].

Pediatric musculoskeletal infections represent a diagnostic challenge due to varying clinical presentations and symptoms overlapping with noninfectious diagnoses [14]. Prompt evaluation and management are required to avoid treatment delays [14]. Findings can assist clinicians in early recognition and management of coexisting adjacent septic arthritis in children with acute hematogenous osteomyelitis, especially when MRI is not readily available or inconclusive [16]. Duration of symptoms, presence of osteomyelitis, and the pathogenic organism are prognostic features for suppurative arthritis of the hip in children [17].

Delayed treatment of purulent flexor tenosynovitis leads to worse functional outcomes, as do infections with specific pathogens [3]. Prompt diagnosis and early debridement are of the utmost importance to improve outcomes for invasive Group A Streptococcus hand infections [19]. With early diagnosis and prompt treatment, septic arthritis after arthroscopic anterior cruciate ligament reconstruction can be successfully eradicated [6]. Early consideration in differential diagnoses is crucial for chronic, painful swelling, nodular or inflammatory lesions, or septic arthritis caused by nonmarinum nontuberculous mycobacterial infections of the upper extremity [13].

Favorable outcomes in spondylodiscitis correlate with normalized CRP levels and antibiotic therapy duration greater than 6 weeks [4]. Concomitant infections correlate with unfavorable outcomes in spondylodiscitis [4]. ESR and CRP often remain elevated even after infection eradication, meaning no specific tests can currently guide the stopping of antimicrobial agents [10]. The outcome of Kocuria species infections mainly depends on the type of infection, with higher outcomes for infective endocarditis [8]. Diagnosis of hand tuberculosis is often delayed, leading to worse outcomes [7]. Early diagnosis by sending fluid or tissue samples for culture is vital to ensure the best outcome for skeletal tuberculosis presenting as elbow pain, as is prompt treatment of mycobacterial infection [36].

Investigations

Laboratory: Early and accurate diagnosis of infectious spondylitis is critical for preventing long-term complications [1]. For persistent symptoms of local myofascitis, infection should be considered, blood tests and imaging should be performed, and empirical antibiotic administration should be considered [2]. Infectious causes should be considered in the workup of patients who present with common signs and symptoms but do not respond to initial nonoperative treatment [5].

MRI: Magnetic resonance imaging is a non-invasive, non-irradiating imaging modality that provides necessary anatomical detail to determine the extent of infection and the condition of surrounding soft tissues in children with discitis [37]. Due to multifocal spondylodiscitis being found in approximately 13% of cases, MRI imaging of the total spine is recommended to avoid overlooking additional infection levels [42]. Early use of MRI helps delineate the extent of infection in methicillin-resistant Staphylococcus aureus bone and joint infections in children [50]. Early use of MRI aids in the consideration of surgery for methicillin-resistant Staphylococcus aureus bone and joint infections in children [50]. Early use of MRI provides valuable information for surgical planning for methicillin-resistant Staphylococcus aureus bone and joint infections in children [50]. Findings can assist clinicians in early recognition and management of coexisting adjacent septic arthritis in children with acute hematogenous osteomyelitis, especially in situations where MRI is not readily available or when its findings are inconclusive [16]. Follow-up MRI findings of pyogenic spondylodiscitis show variable tissue responses [44]. P. acnes can survive within the end-plate region and can initiate mild inflammatory-like responses from host cells, leading to signal intensity changes in MRI scans [54]. Signal intensity changes in MRI scans caused by P. acnes potentially resemble Modic changes [54].

CT: Imaging methods including computed tomography, magnetic resonance imaging, and nuclear medicine techniques have the potential to demonstrate the extent of soft-tissue and bone involvement in patients with periprosthetic joint infection [43]. Imaging methods including computed tomography, magnetic resonance imaging, and nuclear medicine techniques may help guide bone resection in patients with periprosthetic joint infection [43].

Bone scan: All available imaging modalities, including conventional imaging such as plain radiography, CT, MRI, and WBC scintigraphy, have limited accuracy and should not be used as standalone tests to identify osteomyelitis [40].

Plain radiography: Radiological signs suggestive of infection were uncommon for diagnosing internal fixation-associated infection [38].

Aspiration: Image-guided biopsy has a reasonably high diagnostic yield in patients with suspected infectious spondylodiscitis [63].

Other Considerations: Early consideration in the differential diagnoses of chronic, painful swelling, nodular or inflammatory lesions, or septic arthritis is crucial for nonmarinum, nontuberculous mycobacterial infections of the upper extremity [13]. Tissue biopsy and early involvement with an infectious disease specialist are recommended for nonmarinum, nontuberculous mycobacterial infections of the upper extremity [13]. Improvements in radiologic imaging and antibiotic treatment have led to earlier detection and decreased morbidity and mortality in acute hematogenous osteomyelitis in children [12]. The clinical manifestations of Aspergillus spondylitis are non-specific [58]. Diagnosis of Aspergillus spondylitis depends on imaging and microbiological/histopathological findings [58]. Children with primary septic arthritis are sufficiently distinguishable from those with contiguous osteomyelitis to guide decisions for MRI acquisition, antibiotic therapy duration, and outpatient follow-up [59]. Advanced imaging offers a complementary approach to distinguish between Charcot neuroarthropathy and osteomyelitis [60].

Treatment

Early and accurate diagnosis of infectious spondylitis is critical for preventing long-term complications [1]. Infections with specific pathogens lead to worse functional outcomes in purulent flexor tenosynovitis, and delayed treatment leads to worse functional outcomes [3]. Prompt evaluation and management are required for pediatric musculoskeletal infections to avoid treatment delays, as these cases represent a diagnostic challenge due to varying clinical presentations and symptoms overlapping with noninfectious diagnoses [14]. Infectious causes should be considered in the workup of patients who present with common signs and symptoms but do not respond to initial nonoperative treatment [5]. For persistent symptoms of local myofascitis of the deltoid muscle after COVID-19 vaccination, infection should be considered, blood tests and imaging performed, and empirical antibiotic administration considered [2].

Non-Operative

Most patients with spondylodiscitis are successfully treated by conservative means [71]. Favorable outcomes in spondylodiscitis correlate with normalized CRP levels and antibiotic therapy lasting greater than 6 weeks [4]. Treatment with intravenous antibiotics for osteomyelitis of the pubis should be started early and continued for six weeks, with a high expectation that the condition will resolve [51]. A careful assessment of the site and nature of the infection, underlying comorbidities, drug intolerances, and patient preferences should allow for a safe and effective early oral antibiotic switch in most cases of spinal infection [41]. Two patients with chronic Cutibacterium acnes prosthetic shoulder infection showed good clinical outcomes at a minimum of 6 years' follow-up with conservative treatment [70]. Treatment strategies for periprosthetic joint infection should aim to achieve homeostatic control to prevent symptomatic relapse rather than assuming all infections can be eradicated [48]. No specific tests can currently guide the stopping of antimicrobial agents in hip and knee infections, as ESR and CRP often remain elevated even after infection eradication [10]. Nontuberculous mycobacterium infection should be considered when an inflammatory process persists, and treatment should be initiated with a macrolide and ethambutol while awaiting sensitivity results [22].

Operative

Indications: Surgical treatment for spondylodiscitis is indicated for doubtful diagnosis, progressive neurological deficits, progressive spinal deformity, failure to respond to treatment, and unresolved pain [71]. Debridement and retention of implant procedures should be performed urgently after medical optimization, as chronic infections are an absolute contraindication due to mature biofilm formation [18]. Criteria for selecting appropriate candidates for debridement, antibiotics, and implant retention remain complex and require a nuanced understanding of host-, procedural-, and pathogen-specific variables [15]. Prompt diagnosis and early debridement are of the utmost importance to improve outcomes for invasive Group A Streptococcus hand infections [19]. Timely diagnosis and treatment are essential to reduce the severity of septic shoulder infection [52]. Patients presenting with acute fight bites with infection or delayed presentation require operative debridement [56]. Deterioration in clinical condition or a poor response to conservative treatment for upper extremity infections following carp fish handling requires meticulous surgical drainage and excision of both infected and necrotic tissues [46].

Surgical Approach / Technique: Treatment of acute hand infections requires a combination of surgical intervention (incision and drainage) and appropriate antibiotic therapy tailored to the organism and infection severity [24]. The best treatment for primary pyogenic abscess of the psoas muscle is early operative drainage and administration of systemic antibiotics [66]. With early diagnosis and prompt treatment, septic arthritis after arthroscopic anterior cruciate ligament reconstruction can be successfully eradicated [6]. The focus of treatment for prophylactic antibiotics in open distal phalanx fractures should be on prompt irrigation and debridement rather than administration of prophylactic antibiotics [57].

Adjuncts: Despite its high initial cost, PET/CT demonstrates long-term cost-effectiveness by improving infection management and reducing recurrence rates in refractory fracture-related infection on lower limbs [55].

Other Considerations: Concomitant infections correlate with unfavorable outcomes in spondylodiscitis [4]. Clinical outcomes for reverse total shoulder arthroplasty are inferior in patients with previous native shoulder infection compared to those without past infection [25]. There was no difference in final outcomes between patients with shoulder periprosthetic joint infection and those revised for noninfectious indications [20]. Unsatisfactory clinical results in shoulder arthroplasty for postinfectious glenohumeral arthritis may be secondary to the initial insult of infection, although overall pain and motion can be expected to improve [47]. The functional outcome for tubercular infection after arthroscopic rotator cuff repair can be poor due to repeated surgeries and arthritic changes, even if the infection is well controlled [45]. The time to diagnosis and treatment is a major factor influencing outcome in pyarthrosis of the small joints of the hand resulting in arthrodesis or amputation [53]. The number of incision and drainage procedures is a major factor influencing outcome in pyarthrosis of the small joints of the hand resulting in arthrodesis or amputation [53]. Patient comorbidities are a major factor influencing outcome in pyarthrosis of the small joints of the hand resulting in arthrodesis or amputation [53]. Postoperative infection following non-joint surgery is a major factor influencing outcome in pyarthrosis of the small joints of the hand resulting in arthrodesis or amputation [53]. Patients presenting with acute fight bites within 24 hours generally have excellent outcomes regardless of treatment [56].

Complications

Infection (PJI): The natural history of periprosthetic joint infection (PJI) represents a continuum from initiation to chronicity, with no evidence-based time interval dividing acute from chronic disease [11]. While the periprosthetic infection rate after total shoulder arthroplasty remains low at 20-year follow-up [31], the risk of failure after one-year follow-up is high following revision knee arthroplasty due to PJI [30]. Mycobacterial infections in PJI are rare but carry specific risk factors including immunocompromised status, corticosteroid therapy, multiple medical comorbidities, prior tuberculosis history, and multiple prior surgeries [80]. Gram-negative rods are associated with prolonged treatment in thoracolumbar pyogenic spondylitis after minimally invasive posterior fixation compared with gram-positive cocci [87].

Wound complications: The overall incidence of serious wound complications after total elbow arthroplasty is slightly less than 5.5%, with approximately 25% of these progressing to sepsis [23]. Half of the serious wound complications that progress to sepsis require implant removal [23]. Short-term, 30-day surgical site infections occur in approximately 1% of patients undergoing total joint arthroplasty (TJA) [72]. A successfully treated superficial infection following total knee arthroplasty (TKA) does not result in inferior clinical outcome or health-related quality of life compared to TKA without complications [26].

Pediatric and Specific Pathogen Complications: Early and accurate diagnosis of infectious spondylitis is critical for preventing long-term complications [1]. In children, the etiology of narrowing of the intervertebral-disc space is very likely infectious, potentially linked to trauma in the presence of transient bacteremia [9]. Improvements in radiologic imaging and antibiotic treatment have led to earlier detection of acute hematogenous osteomyelitis in children, resulting in decreased morbidity and mortality [12]. Delayed treatment of purulent flexor tenosynovitis leads to worse functional outcomes, a risk exacerbated by specific pathogens [3]. Diagnosis of hand tuberculosis is often delayed, leading to worse outcomes, though prompt evaluation, appropriate antibiotic choice and duration, and surgical management can reduce lasting effects [7, 27]. Close outpatient follow-up is essential to ensure antibiotic compliance and to identify late consequences of pediatric musculoskeletal infection [61].

Other Considerations: The increased risk of infection with time in patients with transfemoral amputations treated with osseointegration prostheses calls for patient awareness of long-term risks and heightened surgical suspicion [28]. US veterans with a history of Hepatitis C are at an increased risk of developing medical complications within the first year after total shoulder arthroplasty but are not at an increased risk of developing surgical complications [84]. The greatest risk factors for infection after reverse shoulder arthroplasty are a history of a prior failed arthroplasty and age younger than 65 years [75]. There is a significant trend toward a lower incidence of deep infection when prophylactic antibiotics are given for knee scope, though infections occur regardless of antibiotic use [85]. Older age and a history of abdominal-pelvic infections tend to complicate management in patients with thoracolumbar pyogenic spondylitis after minimally invasive posterior fixation [87]. Suppressing pro-inflammatory mechanisms or improving inflammation resolution may delay age-related diseases [29].

Recovery

Light activity (weeks): Early and accurate diagnosis of infectious spondylitis is critical for preventing long-term complications [1], while delayed treatment of purulent flexor tenosynovitis leads to worse functional outcomes [3]. Infections with specific pathogens in purulent flexor tenosynovitis also lead to worse functional outcomes [3]. Early diagnosis and prompt treatment of septic arthritis after arthroscopic anterior cruciate ligament reconstruction allow for successful eradication of the infection [6]. Diagnosis of hand tuberculosis is often delayed, leading to worse outcomes [7], though prompt evaluation, appropriate antibiotic choice and duration, and surgical management as needed are key to reducing lasting effects of mycobacterial infections of the hand [27].

Full activity (months): Favorable outcomes in spondylodiscitis correlate with normalized CRP levels [4] and antibiotic therapy duration greater than 6 weeks [4]. Concomitant infections in spondylodiscitis correlate with unfavorable outcomes [4]. Clinical outcomes for reverse total shoulder arthroplasty are inferior in patients with previous native shoulder infection compared to those without past infection [25]. A successfully treated superficial wound infection following total knee arthroplasty (TKA) does not result in inferior long-term clinical outcomes or health-related quality of life compared to TKA without complications [26]. Patients with surgical site infection (SSI) initially (6 months) after open posterior instrumented thoracolumbar surgery had poorer overall physical function representing a delay to recovery [67].

Complete recovery / outcome plateau (months): The negative impact of surgical site infection on physical function after open posterior instrumented thoracolumbar surgery resolved by the first postoperative year [67]. Reasonable long-term functional outcome scores can be achieved after infected mini-open rotator cuff repair [68]. At 4-year follow-up, a patient with chronic Mycobacterium infection of the first dorsal web space had no recurrent infection and excellent hand function [69]. Post-revision antibiotic therapy after single-stage revision shoulder arthroplasty was associated with an infection-free survival rate of 91% at a mean of greater than 4 years of follow-up [73]. The prognosis for complete return of joint function in Hemophilus influenzae septic arthritis in adults is excellent if appropriate therapy is initiated promptly [104].

Rehabilitation protocol: There is no evidence-based time interval that divides acute from chronic periprosthetic joint infection (PJI) [11], as the natural history of periprosthetic joint infection is a continuum from initiation to chronicity [11]. Improvements in radiologic imaging and antibiotic treatment for acute hematogenous osteomyelitis in children have led to earlier detection [12] and decreased morbidity and mortality [12]. Duration of symptoms is a prognostic feature for suppurative arthritis of the hip in children [17], as is the presence of osteomyelitis [17] and the pathogenic organism [17]. Most acute Schmorl's nodes respond well to conservative treatment [105], though rapid deterioration of symptoms or persistent severe pain in an infected Schmorl's node should raise suspicion of underlying secondary pathology [105].

Functional milestones: The risk of failure after one-year follow-up is high after revision for periprosthetic joint infection [30]. The periprosthetic infection rate after total shoulder arthroplasty was low at 20-year follow-up [31]. Appropriate drug therapy is the mainstay of treatment for hand tuberculosis [7]. The increased risk of infection in patients with transfemoral amputations treated with osseointegration prostheses calls for patient awareness of long-term risks [28] and heightened surgical suspicion [28].

Key Evidence

• [L5] Early and accurate diagnosis of infectious spondylitis is critical for preventing long-term complications. (10.1186/s13018-025-05781-5)
• [L5] The authors recommend considering infection, performing blood tests and imaging, and considering empirical antibiotic administration for persistent symptoms. (10.1016/j.xrrt.2022.04.005)
• [L4] Delayed treatment and infections with specific pathogens led to a worse outcome. (10.1177/1753193408087071)
• [L3] Favorable outcomes correlate with normalized CRP and antibiotic therapy >6 weeks, while concomitant infections correlate with unfavorable outcomes. (10.3390/brainsci11081019)
• [L4] Infectious causes should be considered in the workup of patients who present with common signs and symptoms but do not respond to initial nonoperative treatment. (10.2106/jbjs.i.00212)
• [L4] With early diagnosis and prompt treatment, the infection can be successfully eradicated. (10.1016/j.arthro.2008.10.002)
• [L5] The article reviews the epidemiology, bacteriology, pathophysiology, diagnosis, and treatment principles of hand tuberculosis, emphasizing that diagnosis is often delayed leading to worse outcomes and that appropriate drug therapy is the mainstay of treatment. (10.1016/j.jhsa.2011.05.036)
• [L4] The infection outcome mainly depends on the type of infection and is higher for infective endocarditis. (10.3390/microorganisms11092362)
• [L5] No specific tests can currently guide the stopping of antimicrobial agents, as ESR and CRP often remain elevated even after infection eradication. (10.1016/j.arth.2018.09.032)
• [L5] There is no evidence-based time interval that divides acute from chronic periprosthetic joint infection (PJI); the natural history of infection is a continuum from initiation to chronicity. (10.1016/j.arth.2018.09.069)
• [L4] Improvements in radiologic imaging and antibiotic treatment have led to earlier detection and decreased morbidity and mortality. (10.5435/00124635-200105000-00003)
• [L4] Early consideration in differential diagnoses of chronic, painful swelling, nodular or inflammatory lesions, or septic arthritis is crucial, with tissue biopsy and early involvement with an infectious disease specialist recommended. (10.1016/j.jhsa.2022.03.019)
• [L4] Criteria for selecting appropriate candidates remain complex and require a nuanced understanding of host-, procedural-, and pathogen-specific variables. (10.1016/j.arth.2025.10.076)
• [L3] These findings can assist clinicians in early recognition and management of coexisting infections, especially in situations where MRI is not readily available or when its findings are inconclusive. (10.1186/s12891-025-08671-3)
• [L4] Duration of symptoms, presence of osteomyelitis, and the pathogenic organism are the most important prognostic features. (10.2106/00004623-197658030-00017)
• [L4] While not an absolute emergency, the procedure should be performed urgently after medical optimization, as chronic infections are an absolute contraindication due to mature biofilm formation. (10.1016/j.arth.2018.09.025)
• [L4] Prompt diagnosis and early debridement are of the utmost importance to improve outcomes for these often limb- and life-threatening infections. (10.1177/17531934241268983)
• [L3] There was no difference in final outcomes between patients with shoulder periprosthetic joint infection and those revised for noninfectious indications. (10.1016/j.jse.2018.07.014)
• [L5] The development of a consensus definition of a periprosthetic shoulder infection is critical to future investigations of these devastating complications. (10.2106/jbjs.m.00402)
• [L4] The authors recommend considering nontuberculous mycobacterium infection when an inflammatory process persists and initiating treatment with a macrolide and ethambutol while awaiting sensitivity results. (10.1016/j.jhsa.2017.09.008)
• [L4] The overall incidence of serious wound complications was slightly less than anticipated (5.5%); however, the significance was considerable, with approximately 25% of complications progressing to sepsis and half of those requiring implant removal. (10.1016/j.jse.2011.03.005)
• [L5] Treatment requires a combination of surgical intervention (incision and drainage) and appropriate antibiotic therapy tailored to the organism and infection severity. (10.1016/j.jhsa.2014.03.031)
• [L3] Clinical outcomes are inferior to those without past infection. (10.1016/j.jse.2020.04.048)
• [L3] In a long-term follow-up, a different clinical outcome and HRQoL were not obtained after a successfully treated superficial infection following a TKA when compared to a TKA without complications. (10.1007/s00167-016-4290-z)
• [L4] Prompt evaluation, including a thorough history to evaluate for potential exposures to infectious sources, followed by appropriate antibiotic choice and duration, with surgical management as needed, is key to reducing the chance that patients experience lasting effects of the infection. (10.1177/1558944720940064)
• [L4] The increased risk of infection with time calls for numerous measures, including patient awareness of long-term risks and heightened surgical suspicion. (10.1007/s11999-017-5507-2)
• [L5] The article discusses molecular pathways associated with 'inflamm-aging' and cytokine dysregulation, suggesting that suppressing pro-inflammatory mechanisms or improving inflammation resolution may delay age-related diseases, while learning from long-lived cohorts could offer insights into healthy aging. (10.3389/fimmu.2018.00586)
• [L3] The risk of failure after one-year follow-up is high after revision for periprosthetic joint infection. (10.1002/ksa.12762)
• [L4] The periprosthetic infection rate was low at 20-year follow-up. (10.1016/j.jse.2012.01.006)
• [L4] Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms; early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism. (10.1016/j.jhsa.2025.09.023)
• [L4] Septic arthritis in rheumatoid arthritis patients is difficult to identify and requires a high degree of clinical suspicion; early diagnosis is crucial to prevent disastrous sequelae. (10.1186/1749-799x-3-33)
• [L5] Diagnosis of spinal tuberculosis in the early inflammatory stage is essential to prevent deformity and neurological deficit. (10.2106/jbjs.19.00001)
• [L3] In the absence of abnormal clinical signs and symptoms, postoperative leukocytosis may not warrant further workup for infection. (10.1007/s11999-011-1887-x)
• [L4] Early diagnosis by sending fluid or tissue samples for culture with prompt treatment of mycobacterial infection is vital to ensure the best outcome. (10.1016/j.jse.2007.02.129)
• [L4] Magnetic resonance imaging is a non-invasive, non-irradiating imaging modality that provides necessary anatomical detail to determine the extent of infection and the condition of surrounding soft tissues in children with discitis. (10.2106/00004623-198870060-00022)
• [L2] Radiological signs suggestive of infection were uncommon. (10.1186/s12891-021-04170-3)
• [L3] Consecutive fevers or fever ≥39 °C after total joint arthroplasty may be indicative of postoperative infection, and testing to rule out infection should be performed. (10.1007/s00167-014-3098-y)
• [L3] All available imaging modalities, including conventional imaging such as plain radiography, CT, MRI, and WBC scintigraphy, have limited accuracy and should not be used as standalone tests to identify osteomyelitis. (10.1016/j.arth.2025.10.083)
• [Letter] A careful assessment of the site and nature of the infection, underlying comorbidities, drug intolerances, and patient preferences should allow for, in most cases of spinal infection, a safe and effective early oral antibiotic switch. (10.5435/jaaos-d-25-00625)
• [L3] Due to multifocal spondylodiscitis being found in approximately 13% of cases, MRI imaging of the total spine is recommended to avoid overlooking additional infection levels, which can impact the therapeutic strategy chosen. (10.1186/s12891-020-03928-5)
• [L4] Imaging methods including computed tomography, magnetic resonance imaging, and nuclear medicine techniques have the potential to demonstrate the extent of soft-tissue and bone involvement in patients with periprosthetic joint infection and may help guide bone resection. (10.1016/j.arth.2018.09.073)
• [L3] Follow-up MRI findings of pyogenic spondylodiscitis show variable tissue responses. (10.1186/s12891-020-03446-4)
• [L5] The infection was well controlled with treatment, but the functional outcome was poor due to repeated surgeries and arthritic changes. (10.1007/s00167-015-3968-y)
• [L4] Deterioration in the clinical condition or a poor response to conservative treatment requires a meticulous surgical drainage and excision of both infected and necrotic tissues. (10.1054/jhsb.2001.0660)
• [L4] Although overall pain and motion can be expected to improve, unsatisfactory clinical results are not uncommon and may be secondary to the initial insult of infection. (10.1016/j.jse.2013.12.011)
• [L4] Treatment strategies should aim to achieve homeostatic control to prevent symptomatic relapse rather than assuming all infections can be eradicated, challenging the false dichotomy of infection eradication versus recurrence. (10.1016/j.arth.2025.10.033)
• [L3] Patients with a classification of Grade III or higher in the novel classification system had higher reinfection rates than those with a classification of Grade I or II and required more aggressive treatment to eradicate the infection. (10.2106/jbjs.19.00951)
• [L5] Early use of MRI helps delineate the extent of infection, aids in the consideration of surgery, and provides valuable information for surgical planning. (10.5435/jaaos-23-01-29)
• [L4] Treatment with intravenous antibiotics should be started early and continued for six weeks, with a high expectation that the infection will resolve. (10.2106/00004623-200405000-00027)
• [L3] To reduce the severity of septic shoulder infection, timely diagnosis and treatment are essential. (10.1016/j.jse.2021.05.020)
• [L3] The time to diagnosis and treatment, the number of I and D procedures, patient comorbidities, and postoperative infection following non-joint surgery are major factors influencing outcome. (10.1016/j.jhsa.2011.05.022)
• [L5] P. acnes can survive within the end-plate region and can initiate mild inflammatory-like responses from host cells, leading to signal intensity changes in MRI scans, which potentially resemble Modic changes. (10.2106/jbjs.16.00146)
• [L3] Despite its high initial cost, PET/CT demonstrates long-term costeffectiveness by improving infection management and reducing recurrence rates. (10.1302/0301-620x.107b8.bjj-2024-1158.r2)
• [L4] Patients presenting within 24 hours generally have excellent outcomes regardless of treatment, whereas those presenting with infection or delayed presentation require operative debridement. (10.1016/j.jhsa.2013.03.002)
• [L1] The focus of treatment should be on prompt irrigation and debridement rather than administration of prophylactic antibiotics. (10.1177/1753193415601055)
• [L4] The clinical manifestations of Aspergillus spondylitis are non-specific, and diagnosis depends on imaging and microbiological/histopathological findings. (10.1186/s12891-020-03582-x)
• [L3] Children with primary septic arthritis are sufficiently distinguishable from those with contiguous osteomyelitis to guide decisions for MRI acquisition, antibiotic therapy duration, and outpatient follow-up. (10.2106/jbjs.20.01685)
• [L4] Advanced imaging offers a complementary approach to distinguish between Charcot neuroarthropathy and osteomyelitis. (10.3390/tomography10080098)
• [L5] Close outpatient follow-up is essential to ensure antibiotic compliance and to identify late consequences of the infection. (10.5435/00124635-200910000-00004)
• [L2] Image-guided biopsy has a reasonably high diagnostic yield in patients with suspected infectious spondylodiscitis. (10.1302/0301-620x.104b1.bjj-2021-0848.r2)
• [L3] The authors propose a comprehensive system for the classification and management of spontaneous shoulder sepsis based on stage and anatomy, noting that preoperative MRI can aid in determining disease severity and surgical decision-making. (10.1016/j.jse.2023.05.019)
• [L4] While the diagnosis of shoulder periprosthetic joint infection has improved with the advent of International Consensus Meeting criteria, there remain distinct differences between periprosthetic joint infection classifications that warrant further investigation to determine the accurate diagnosis and optimal treatment. (10.1177/17585732211019010)
• [L4] The best treatment is early operative drainage and administration of systemic antibiotics. (10.2106/00004623-199305000-00021)
• [L3] Patients with SSI initially (6 months) had poorer overall physical function representing the delay to recovery; however, the negative impact resolved by the first postoperative year. (10.2106/jbjs.20.02141)
• [L4] Reasonable long-term functional outcome scores can be achieved. (10.1016/j.jse.2017.09.003)
• [Case_report] At 4-year follow-up, there was no recurrent infection and the patient had excellent hand function. (10.1016/j.jhsa.2008.05.019)
• [L4] Our 2 patients showed good clinical outcomes at a minimum of 6 years' follow-up with conservative treatment of chronic prosthetic shoulder infections. (10.1016/j.jses.2019.03.005)
• [L5] Most patients with spondylodiscitis are successfully treated by conservative means; however, surgical treatment is indicated for doubtful diagnosis, progressive neurological deficits, progressive spinal deformity, failure to respond to treatment, and unresolved pain. (10.1302/2058-5241.2.160062)
• [L4] Post-revision antibiotic therapy was associated with an infection-free survival rate of 91% at a mean of >4 years of follow-up. (10.2106/jbjs.20.02263)
• [L5] The workgroup proposes a universal definition for periprosthetic joint infection (PJI) based on evaluated evidence to standardize diagnosis and facilitate comparison of published evidence. (10.1016/j.arth.2011.09.026)
• [L3] The greatest risk factors for infection after RSA were history of a prior failed arthroplasty and age younger than 65 years. (10.1016/j.jse.2014.05.020)
• [Paper] The workgroup proposes a new definition for periprosthetic joint infection (PJI) to serve as a 'gold standard' that can be universally adopted by clinicians, surveillance authorities, and researchers to ensure consistency in diagnosis and management. (10.1007/s11999-011-2102-9)
• [L5] Hand infections include a diverse array of entities with potential for serious morbidity. (10.1016/j.jhsa.2011.05.035)
• [L5] Chronic hand infections are uncommon and require a high index of suspicion for early diagnosis; they are grouped by microorganism into bacterial (mycobacterial and others), fungal, and viral types, with specific presentations and treatments emphasized for each. (10.1016/j.jhsa.2014.04.003)
• [L3] The developed risk stratification tools allow one to predict the likelihood of septic arthritis in both groups. (10.5435/jaaos-d-21-00053)
• [L4] Mycobacterial infections in periprosthetic joint infection are rare, with risk factors including immunocompromised status, corticosteroid therapy, multiple medical comorbidities, prior tuberculosis history, and multiple prior surgeries. (10.1016/j.arth.2025.08.037)
• [L5] Charcot arthropathy of the spine is a progressive disorder involving a destructive process of the anatomical elements which provide spinal stability, often with delayed clinical recognition. (10.5435/jaaos-d-22-00212)
• [L2] The evidence supports conceptualizing C. acnes as a common commensal and frequent contaminant, and an uncommon cause of an inflammatory host response. (10.1016/j.jse.2024.07.038)
• [L5] The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage. (10.1016/j.jse.2024.12.023)
• [L3] US veterans with a history of HCV are at an increased risk of developing medical but not surgical complications within the first year after TSA. (10.1016/j.jseint.2021.02.009)
• [L5] Infections are going to occur whether or not prophylactic antibiotics are used, but there is a significant trend toward a lower incidence of deep infection when antibiotics are given. (10.1016/j.arthro.2016.10.012)
• [L5] Mechanical loading plays an important role for cellular and matrix responses in tendon. (10.1371/journal.pone.0086078)
• [L3] Older age and a history of abdominal-pelvic infections tend to complicate the management in these patients; therefore, tailored treatment strategies are required to optimize treatment duration and minimize complications. (10.1186/s12891-025-08489-z)
• [L1] The spinal fixation mechanical failure rate was 10%. (10.1186/s13018-022-03007-6)
• [L3] The difference between thoracic and lumbar posterior vertebral wall morphology is a reason that the rate of bone cement leakage into the thoracic spinal canal is significantly higher than that into the lumbar spinal canal. (10.1186/s12891-019-2807-6)
• [L4] Anatomical variations in the apophyseal articular processes between the second and third cervical vertebrae are frequent and may produce irregular motion and joint instability, potentially contributing to headaches and nerve irritation. (10.2106/00004623-195234010-00017)
• [L4] Preoperative planning to accurately select and insert pedicle screws in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree. (10.1186/s12891-022-05799-4)
• [L4] If the diagnosis and treatment are delayed, spinal damage and other consequences might be incurable. (10.1186/s12891-021-04426-y)
• [L4] The prognosis for complete return of joint function in this infection is excellent if appropriate therapy is initiated promptly. (10.2106/00004623-197456020-00021)
• [Case_report] Most of the time acute Schmorl's node responds well to conservative treatment; however, rapid deterioration of symptoms or persistent severe pain should give suspicion of underlying secondary pathology. (10.1186/s12891-020-03276-4)

See Also

• Conservative Treatment
• Surgical Complications

References

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