The work, published in the Journal of Bone and Joint Infection, was coordinated through the African Bone and Joint Infection Network under the auspices of the European Bone and Joint Infection Society, with support from the AO Alliance. Led by Loïc Fonkoué of Yaoundé General Hospital in Cameroon and Elizabeth Tissingh of King’s College London, the group spanned 14 countries, from Ethiopia and Malawi to Switzerland and the United Kingdom. Every member had direct experience treating bone and joint infections in resource-limited environments, a deliberate design choice meant to ensure the recommendations reflect clinical reality rather than idealized conditions.

The recommendations were built through a three-step process. First, two 34-item questionnaires were distributed to network members in November 2024, gathering responses from 86 clinicians in 22 countries about their current practice and their most urgent needs. Second, a one-day consensus meeting was held during the annual congress of the College of Surgeons of East Central and Southern Africa in Harare, Zimbabwe, in December 2024, where a draft document was agreed upon. Third, the wider panel conducted an iterative collaborative review from December 2024 to February 2025, revising recommendations until broad agreement was reached. Notably, the group did not use formal voting or evidence grading, acknowledging that the evidence base from low-income settings is too thin for such methods.

A central technical point of the guidance is terminology and diagnosis. The experts endorse the term fracture-related infection, or FRI, which supersedes older labels such as post-traumatic osteomyelitis and fracture-fixation-associated infection. Because it is impossible to reliably distinguish deep from superficial infection after a fracture, any surgical-site infection following a fracture is considered an FRI. Diagnosis should rest primarily on clinical criteria: sinus tracts, purulence, wound breakdown, and delayed or failed bone healing all warrant suspicion. This emphasis matters because late presentation is common in low-resource settings, and by the time patients arrive, the classic confirmatory signs are often the only reliable indicators available.

The guidelines are equally pragmatic about laboratory and imaging resources. Wound swabs and sinus tract samples are explicitly discouraged for microbiological culture, since they tend to grow skin commensals that do not represent the true pathogen. Instead, intra-operative tissue sampling is the diagnostic test of choice: five samples taken with separate clean instruments raise diagnostic yield to 97 percent, compared with 84 percent for three samples, though three samples are deemed acceptable under constraint. Routine X-rays should be prioritized over costly CT, MRI, or nuclear imaging, which are helpful but not essential. Histology offers a low-cost adjunct, with more than five neutrophils per high-power field considered significant, a technique accessible even in laboratories that mainly process malaria blood films.

Perhaps the most striking technical content concerns antibiotic strategy. Data from Cameroon and Nigeria show that Gram-negative bacteria account for 65.8 percent and 49 percent of fracture-related infections respectively, a markedly different profile from high-income countries where Staphylococcus aureus dominates. The experts therefore recommend empirical therapy combining a glycopeptide, such as vancomycin, with an agent active against Gram-negatives, such as amikacin or meropenem, with cefazolin plus gentamicin as a fallback. For definitive oral therapy, they favor bactericidal drugs with high oral bioavailability and good bone penetration, including rifampicin, fluoroquinolones, clindamycin, and fosfomycin, while cautioning against cephalosporins for oral use and against the rifampicin-clindamycin combination, which risks inducible resistance.

Local antibiotic delivery receives detailed attention because it demonstrably works: in a study of 433 confirmed infections, adding local antibiotics to definitive management cut failure rates from 18.3 percent to 10.3 percent. Polymethylmethacrylate cement, readily available and affordable across Africa, can be fashioned into spacers or beads, though it requires removal surgery and has poorer drug elution than absorbable calcium sulfate and composite ceramic carriers. The guidelines also flag a practical dilemma: rifampicin, the cornerstone of anti-biofilm therapy for implant retention, is often restricted to tuberculosis treatment programs in African countries. Encouragingly, evidence from the SOLARIO trial suggests that when local antibiotic carriers are used, as little as seven days of systemic therapy may suffice, a finding with major implications for adherence and antimicrobial stewardship.

On the surgical side, the recommendations preserve the universal principles of meticulous debridement of dead tissue until punctate bleeding appears, copious low-pressure saline irrigation without additives, and rigid fracture stabilization. But they also codify resource-adapted innovations. Where patients cannot afford a new implant, the group endorses debridement and implant sterilization, in which the removed hardware is re-sterilized and reused during the same operation. Debridement and implant retention is favored for early infections when fixation is stable, since implants are scarce. For dead-space management, options range from the induced-membrane Masquelet technique with cement to antibiotic-impregnated bone autografts and bone transport using external frames. The group also warns against prolonged vacuum-assisted dressings, citing evidence that negative pressure wound therapy more than doubles recurrence risk in fracture-related infection.

Prevention and system-level reform round out the guidance. Improved early management of open fractures, which can become infected in up to 52 percent of cases in some series, is identified as the single most effective strategy for reducing the disease burden, alongside WHO surgical safety checklists, engagement with community leaders and traditional bone setters to reduce treatment delays, and optimization of comorbidities including HIV, diabetes, anemia, and malnutrition. The recommendations have been packaged as the seventh ACTIONS guideline, part of the African Consensus for Trauma in Orthopaedics: National Standards series, and are available in English, French, and Portuguese to maximize uptake across the continent.

The authors are candid about the limitations: much of the guidance rests on expert consensus rather than trials conducted in the settings it targets, and urgent research priorities include building treatment networks, defining optimal antibiotic regimens and sampling protocols, and establishing supply chains for local antibiotic carriers and circular fixators. They call on ministries of health, clinicians, and industry to invest in training, reconstructive capacity, and diagnostics. The guidelines do not replace international standards, the authors stress; rather, they translate essential principles into feasible strategies for the hospitals where the burden of bone infection is greatest, while insisting that robust audit and locally generated evidence will be needed to refine them for the future.

Subject of Research: Consensus guidelines for managing fracture-related infection in low-resource settings in Africa

Article Title: Management of fracture-related infection in low-resource settings in Africa: recommendations and guidelines from an international expert group

Article References: Fonkoué, L., Tissingh, E. K., Marais, L. C., Malaba, M., Abrha, K., Ferguson, J., Morgenstern, M., Cornu, O., Laubscher, M., Buzisa Mbuku, R., Galiwango, G. W., Botman, M., Wojno, J., Majigo, M. V., Martin Jr., C., Harrison, W. J., Schade, A. T., Marenah, K., Nyamutora, M., … McNally, M. (2026). Management of fracture-related infection in low-resource settings in Africa: recommendations and guidelines from an international expert group. Journal of Bone and Joint Infection, 11(4), 401-411. https://doi.org/10.5194/jbji-11-401-2026

Image Credits: AI Generated

DOI: 10.5194/jbji-11-401-2026

Keywords: fracture-related infection, osteomyelitis, low-resource settings, Africa, orthopaedic surgery, antibiotic stewardship, consensus guidelines, global health, surgical infection, open fractures, microbiology, AO Alliance

The study was conducted at a high-volume academic tertiary centre that specializes in the treatment of prosthetic joint infections, a complication that affects a small but meaningful fraction of the growing population of patients living with artificial joints. The researchers reviewed the records of 100 patients who underwent DAIR for acute infections of total hip replacements between 2008 and 2021, each with a minimum of two years of follow-up. Acute infections were defined using the 2018 criteria of the Musculoskeletal Infection Society, and included both infections occurring within six weeks of the original hip operation and sudden hematogenous infections, in which bacteria travel through the bloodstream and seed the implant after a symptom-free period. The average age of the patients was nearly 69 years, and more than half were women.

DAIR is the least invasive surgical option for an acute prosthetic joint infection. Rather than removing the entire implant — as required in single- or two-stage revision surgery — surgeons open the joint, thoroughly wash out the infected tissue with at least six litres of saline, exchange the modular components that bacteria can colonize, and then treat the patient with targeted antibiotics. Compared with full revision, DAIR carries less morbidity, costs less, and is technically simpler. But its Achilles heel is the biofilm: once bacteria have built a mature, protective layer on the metal and plastic surfaces of the implant, neither the immune system nor systemic antibiotics can reliably eradicate them, and the only cure is to remove the hardware entirely.

That biological reality is what makes timing so critical. Preclinical work has shown that immature Staphylococcus aureus biofilms can begin forming on implant surfaces as early as three hours after bacterial attachment, and that mature biofilms can develop within 24 hours. Although those laboratory timelines have not been directly translated to patients, they provide a sobering backdrop for the clinical data. Previous studies had already shown that in infected knee replacements, delays of more than 48 hours from admission to DAIR were associated with higher rates of septic reoperation and postoperative complications. In hip fracture care, too, surgery within 48 hours of admission is a well-established benchmark for reducing death and complications. What remained unknown was whether the same clock governed infected hip replacements.

The answer, according to the new analysis, appears to be yes. The mean time from hospital admission to DAIR in the cohort was 46.4 hours, with a wide spread ranging from 3 to 240 hours, and 27 percent of patients waited more than two days for surgery. Using multivariate regression to untangle the effects of age, health status, infection severity, and other variables, the researchers found that each additional hour of delay from admission to the operating room was associated with roughly a 2 percent increase in the odds of death within 90 days — an odds ratio of 1.02 with a confidence interval of 1.00 to 1.03 and a p-value of 0.04. Notably, the time from the onset of symptoms to surgery showed no significant relationship with any outcome, a finding the authors attribute to the inherent subjectivity and unreliability of patient-reported symptom timelines.

The study also identified other, less modifiable risk factors that shaped patient fates. Increasing age raised the risk of death within one year, with each additional year of life corresponding to a 6 percent increase in odds. Patients classified as McPherson host grade C — those with the poorest overall systemic health — faced dramatically elevated risks compared with grade A patients: a nearly thirteenfold increase in one-year mortality and a more than sevenfold increase in postoperative complications. Low preoperative haemoglobin emerged as a significant predictor of reoperation, with each gram-per-litre decrease raising the odds by about 4 percent. The severity of the local extremity condition also mattered, with grade II extremities carrying more than three times the risk of complications compared with grade I.

The raw outcomes of the cohort were sobering. Just over half of the patients — 52 percent — eventually required reoperation for stubborn infection that DAIR could not cure, and patients averaged 1.5 additional hip surgeries after the initial procedure. Thirty percent were readmitted within 90 days, and mortality reached 3 percent at 30 days, 6 percent at 90 days, and 12 percent at one year. Nearly 70 percent experienced postoperative complications, the vast majority of them severe enough to require surgical intervention. The authors caution that their centre is a regional referral hub for the most complex prosthetic joint infections, which likely inflates these failure rates compared with the 58 to 78 percent success rates reported in broader literature. Indeed, 89 percent of the cohort carried an ASA classification of III or IV, indicating severe systemic disease, and the average body mass index of 31 placed most patients in the obese category.

The microbiology added another layer of complexity. Intraoperative cultures revealed a high prevalence of difficult-to-treat pathogens, including polymicrobial infections, methicillin-resistant Staphylococcus aureus, and gram-negative organisms such as Enterococcus, Klebsiella, Enterobacter, and E. coli. Among the patients who died within a year, a quarter had polymicrobial cultures, and Enterococcus and Enterobacter species each appeared in nearly 17 percent of cases — consistent with prior research linking Enterococcus infections after hip replacement to increased mortality. Antibiotic therapy itself was a long haul: the mean initial regimen lasted 37 days, 42 percent of patients required chronic suppressive antibiotics afterwards, and the total antimicrobial exposure averaged more than 333 days per patient. Interestingly, delays beyond 48 hours did not prolong antibiotic courses, suggesting that the harm of waiting manifests through biology rather than through treatment intensity.

Perhaps the most actionable part of the study is its dissection of why delays happen. The mean time from admission to DAIR was about 6.6 hours longer than in a comparable knee infection cohort from the same institution, and the reasons for the longest delays included operating room availability, the need to optimize medical comorbidities, and the management of anticoagulant medications. Many of these barriers are modifiable. Patients on direct oral anticoagulants or warfarin typically wait days for their blood to thin back to a safe range, but reversal agents could be deployed earlier in time-critical infections. Surgeon availability and familiarity with the procedure also contributed, pointing to the value of streamlined protocols, better resource allocation, and clear institutional pathways to the operating suite.

The authors are careful to acknowledge the limits of their work. The retrospective design introduces selection bias, the single-centre cohort of 100 patients produced wide confidence intervals for some estimates, and the 13-year study window spanned changes in electronic records, surgical technique, and implant technology. The study also could not define a precise cutoff — such as the 48-hour benchmark established in knee and hip fracture care — beyond which outcomes deteriorate. Still, the central message is difficult to ignore: in infected hip replacements, the time between admission and surgery is an objective, measurable, and modifiable factor tied to survival. For hospitals, the implication is that prosthetic joint infections deserve the same urgency as hip fractures, with rapid access to the operating room treated not as a convenience but as a clinical imperative. For patients and their families, the takeaway is simpler still — when an artificial joint becomes infected, hours matter.

Subject of Research: The effect of timing from hospital admission to DAIR surgery on mortality and outcomes in acute total hip prosthetic joint infections

Article Title: Timing from admission to debridement, antibiotic, and implant retention (DAIR) affects mortality risk in total hip prosthetic joint infections

Article References: Legler, J., Morgan, S., Beaulé, P., Abdelbary, H., Grammatopoulos, G., & Garceau, S. (2026). Timing from admission to debridement, antibiotic, and implant retention (DAIR) affects mortality risk in total hip prosthetic joint infections. Journal of Bone and Joint Infection, 11(4), 463-477. https://doi.org/10.5194/jbji-11-463-2026

Image Credits: AI Generated

DOI: 10.5194/jbji-11-463-2026

Keywords: prosthetic joint infection, total hip arthroplasty, DAIR, surgical timing, mortality, biofilm, debridement, antibiotics, implant retention, reoperation, orthopaedic surgery, tertiary referral centre

The argument rests on a careful synthesis of two complementary lines of investigation. The first is a scoping review of the published literature on isolation strategies for musculoskeletal infections, which the same group had completed a year earlier. The second is a fresh international survey of clinicians attending the annual meeting of the European Bone and Joint Infection Society in Bologna in 2025. Together, these tools allowed the researchers to do something unusual in infection control: compare what the evidence actually shows with what experienced specialists believe it shows. The gap between the two, they report, is striking and has real consequences for how hospitals allocate scarce beds and staff time.

The technical logic behind the review is straightforward. Musculoskeletal infections encompass fracture-related infections and periprosthetic joint infections, conditions in which bacteria colonize bone, soft tissue, or the surface of an implant. The central fear driving isolation has always been cross-transmission: that a patient harboring a virulent organism could seed it onto environmental surfaces or transfer it via healthcare workers’ hands to another vulnerable patient, particularly one with fresh surgical wounds or implanted hardware. Yet when the researchers systematically examined the literature, they found no studies demonstrating that ward-level isolation, cohorting, or dedicated septic wards reduce cross-transmission, surgical site infection, or reinfection rates for patients whose infections are caused by organisms that remain susceptible to common antibiotics.

This absence of evidence stands in sharp contrast to the situation with multidrug-resistant organisms. For infections involving methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, or carbapenemase-producing Enterobacterales, the literature consistently supports targeted measures, typically single-patient rooms combined with strict transmission-based precautions. The rationale here is not the diagnosis of a bone infection itself but the biology of the organism: these pathogens are harder to eradicate, carry higher risks of colonization, and leave clinicians with a much narrower arsenal of antibiotics. The review’s conclusion, therefore, is not that isolation is meaningless, but that it should be calibrated to the pathogen rather than applied reflexively to every infected patient who walks through the door.

To understand why practice has lagged behind this reasoning, the team surveyed 577 registered members of the European Bone and Joint Infection Society, of whom 157 completed the full questionnaire, a response rate of 27.2 percent. The respondents represented a deliberately broad cross-section of the specialties involved in musculoskeletal infection care: 65.6 percent were orthopaedic and trauma surgeons, 24.2 percent infectious disease specialists, and the remainder microbiologists, infection prevention professionals, plastic surgeons, and pharmacists. Participants were presented with clinically realistic scenarios and asked whether they would permit a patient to share a room with an uninfected orthopaedic patient, allowing the researchers to map how attitudes shift with the pathogen’s resistance profile and the state of the wound.

The results revealed deep divisions, and the fault lines ran along professional boundaries. When asked about a patient with a periprosthetic joint infection caused by methicillin-susceptible Staphylococcus aureus, a fully antibiotic-sensitive bacterium, without any wound complications, 57.1 percent of all respondents judged room-sharing to be unacceptable. But the specialty breakdown was revealing: 70.3 percent of orthopaedic surgeons opposed sharing a room, compared with only 36.8 percent of infectious disease specialists and 14.3 percent of microbiologists, though the microbiologist subgroup was small and should be interpreted cautiously. In other words, the clinicians closest to the operating table were the most likely to insist on separation, even for infections that microbiologically pose the least threat.

Wound appearance proved to be a powerful modifier of perceived risk. When the scenario was changed to a fracture-related infection with a draining fistula, opposition to room-sharing rose to 72.8 percent overall. Yet even here, more than half of infectious disease specialists, 55.6 percent, and microbiologists, 57.1 percent, still considered isolation unnecessary. Perhaps most telling was a comparison embedded in the survey data: for orthopaedic and trauma surgeons, the proportion opposing room-sharing for a methicillin-susceptible infection with wound complications was roughly the same as for a methicillin-resistant infection without wound complications. Visible drainage, in the surgical mind, appeared to confer a transmission risk equivalent to antibiotic resistance itself. The authors note that such concern is biologically plausible, since wound exudate can contaminate the environment, and Staphylococcus aureus transmission between hospitalized patients and via surfaces has been documented elsewhere in healthcare. What is missing is any demonstration that these concerns translate into a measurable benefit of routine isolation in this specific setting.

Agreement emerged where the pathogen was unambiguous. For a patient with a methicillin-resistant joint infection, 84.8 percent of respondents considered room-sharing inappropriate, a near-consensus that mirrors the evidence base. But the survey also exposed a curious blind spot: when asked whether dedicated septic wards are supported by scientific evidence, 49.2 percent of respondents said yes, including 52.3 percent of orthopaedic surgeons and 48.4 percent of infectious disease specialists. Only 14.3 percent of microbiologists shared this belief. That perception persists despite the scoping review’s failure to identify any supporting studies, illustrating how historical practice can outlive its scientific foundation. Structural separation may provide psychological reassurance, the authors observe, but in the absence of demonstrated benefit it must be weighed against its costs in bed capacity, staffing, and patient flow, pressures that have become acute in the post-COVID-19 era.

Not everything in the survey reflected discord. Across all disciplines, there was near-universal agreement, 94.2 percent, on the importance of standardized care pathways and rigorous adherence to standard precautions: hand hygiene, environmental cleaning, and appropriate use of personal protective equipment. This consensus offers a practical path forward, because a risk-based approach to isolation is only as safe as the everyday measures underpinning it. The authors caution that compliance with hand hygiene varies considerably across institutions, a weakness documented in systematic reviews, and that any relaxation of structural isolation must be accompanied by sustained investment in training, education, and auditing. They also acknowledge that single rooms are sometimes preferred for reasons unrelated to infection control, such as privacy, comfort, or the demands of complex wound care and prolonged antimicrobial therapy.

The overall message is a call for differentiation rather than abolition. Routine ward-level isolation for musculoskeletal infections caused by susceptible organisms, the authors conclude, cannot be justified when standard precautions are consistently applied, whereas infections caused by multidrug-resistant organisms, particularly methicillin-resistant Staphylococcus aureus, may warrant single-patient rooms and transmission-based precautions depending on local risk assessment. The survey’s limitations deserve note: it was voluntary, confined to members of a single European society, and may not represent all clinicians caring for these patients. Even so, the study captures something important about how medicine changes. Isolation practices in bone and joint infection care, the authors write, are shaped as much by historical precedent and perceived risk as by scientific evidence. Bridging that gap will require not new buildings or new wards, but a deliberate shift in clinical culture, one that directs infection control resources where the evidence says they matter most and lets go of the traditions that no longer earn their keep.

Subject of Research: Evidence-based patient isolation policies for musculoskeletal infections in orthopaedic care

Article Title: Isolation policies in musculoskeletal infection care: time to move from tradition to evidence

Article References: Bessems, L., Onsea, J., Wouthuyzen-Bakker, M., Sigmund, I. K., Ferry, T., Kuehl, R., Clauss, M., Soriano, A., Sousa, R., Schuermans, A., & Metsemakers, W.-J. (2026). Isolation policies in musculoskeletal infection care: time to move from tradition to evidence. Journal of Bone and Joint Infection, 11(4), 489-492. https://doi.org/10.5194/jbji-11-489-2026

Image Credits: AI Generated

DOI: 10.5194/jbji-11-489-2026

Keywords: musculoskeletal infections, patient isolation, infection control, multidrug-resistant organisms, MRSA, periprosthetic joint infection, fracture-related infection, orthopaedic surgery, standard precautions, septic wards, EBJIS survey, cross-transmission

The scale of the underlying problem is set to grow. The annual number of total hip arthroplasties is projected to rise substantially over the coming decades, driven by population growth and increasing utilization. Although revision rates per implant have gradually declined thanks to better bearing surfaces and fixation, the absolute number of revision procedures continues to climb. Meanwhile, the true incidence of both major complications is likely underestimated. Joint registries capture only fractures requiring stem revision, yet more than half of periprosthetic femoral fractures are treated without stem revision, yielding an estimated true incidence of 0.92 per 1000 prosthesis years. Infection figures suffer from incomplete reporting and failure to update preoperative diagnoses with intraoperative culture results. With an ageing, increasingly comorbid population living longer with prosthetic joints, the absolute burden of both complications is expected to increase sharply.

The coexistence of the two conditions is rarer still, and the authors stress a crucial distinction: a fracture occurring around a chronically infected implant is fundamentally different from an acute infection developing after fracture-fixation surgery. Chronic infection involves a mature biofilm on the implant surface, a microbial fortress that antibiotics alone cannot penetrate, and typically arises in the setting of longstanding infection and septic loosening. Because implant loosening is a well-established risk factor for periprosthetic fracture, septic loosening may further increase fracture susceptibility, although robust data on this relationship remain limited. Existing evidence-based guidelines cover fractures, joint infection, and fracture-related infection separately, but integrating fracture stabilization, infection eradication, and definitive reconstruction in often frail patients has remained an unsolved challenge.

The first patient, a 74-year-old woman with multiple comorbidities, had undergone hip replacement in 2019 for a femoral neck fracture, followed by an Escherichia coli joint infection treated with repeated surgeries, and then presented in 2022 after a low-energy fall. Imaging showed a Vancouver type C fracture around a loosened cemented stem. Fluoroscopy-guided hip aspiration revealed a synovial white blood cell count of 15,880 cells per microliter with 97 percent neutrophils and a positive alpha-defensin test, meeting European Bone and Joint Infection Society criteria for infection; cultures confirmed methicillin-resistant Staphylococcus epidermidis. After multidisciplinary discussion and shared decision-making, the team proceeded with a two-stage revision.

The first stage follows a disciplined dirty-then-clean logic. In the dirty phase, surgeons explant the prosthesis through an extensile approach, perform thorough debridement and lavage, and remove infected tissue and foreign material. In the clean phase, the fracture is stabilized, here with cerclage wiring and a plate-screw construct, and a custom-made antibiotic-loaded cement spacer is implanted to bridge the fracture and deliver high local antibiotic concentrations. For this patient, the spacer was lengthened from a prefabricated device and loaded with meropenem because of her history of ESBL-producing E. coli. Targeted antibiotics were de-escalated to oral minocycline, wounds healed uneventfully, and C-reactive protein normalized. Ten weeks later, the second stage removed the spacer and hardware, confirmed healthy tissues and fracture healing, applied fresh plate fixation to reinforce the femur, and implanted a definitive cemented stem with a dual mobility cup. Three and a half years on, imaging showed complete healing, infection markers stayed normal, and the patient reported better mobility than before her fall.

The second case illustrates how unpredictable these scenarios become. A 56-year-old man with a history of hip resurfacing, early infection, and a two-stage revision for Staphylococcus aureus and Pseudomonas aeruginosa sustained a fracture whose plate fixation failed through non-union. At referral, his synovial fluid showed 59,800 white cells per microliter with 99 percent neutrophils, though cultures were negative, likely suppressed by ongoing antibiotics from the referring hospital. During the first stage, surgeons encountered frank pus along the plate and in the joint; the stem was so well fixed that extraction required an extended trochanteric osteotomy, a controlled cut of the greater trochanter to gain access. Cultures grew P. aeruginosa, treated with eight weeks of oral levofloxacin. At the second stage, with the fracture and osteotomy not yet healed, a new plate construct and a modular revision stem were implanted, but six samples unexpectedly grew Candida albicans, prompting six months of fluconazole alongside the antibacterial course. Two years later, radiographs and CT showed complete healing and normalized inflammatory markers, although patient-reported outcome measures remained poor, a sobering reminder that eradication does not guarantee subjective recovery in complex, comorbid patients.

The third patient, a 76-year-old woman, presented with a draining skin fistula over her anterior incision and a Vancouver B2 fracture after a fall. The fistula was traced and excised down to the implant, the prosthesis was explanted, and the fracture stabilized with a plate extending to the trochanter plus a long antibiotic spacer. Cultures identified Cutibacterium avidum, a slow-growing skin bacterium, treated with oral amoxicillin. Eight weeks after the first stage, all second-stage cultures were negative, a new plate and an uncemented dual mobility cup with a modular fluted titanium revision stem were implanted, and the patient completed twelve weeks of total antibiotic therapy. Seven months after reimplantation she reported no problems, and her patient-reported scores were essentially perfect across pain, symptoms, activities, functioning, and quality of life.

Beyond the outcomes, the paper distills hard-won technical lessons. Diagnosing infection amid a fracture is treacherous: hemarthrosis and local inflammation can produce false-positive synovial white cell counts, especially when the fracture extends into the joint, so the authors reserve the first milliliter of aspirate for cell analysis to minimize blood contamination, and note that molecular diagnostics can add value. Timing matters too: recent studies found no clear correlation between the interval from trauma to definitive surgery and outcomes, including mortality, so postponing surgery until an experienced revision and septic-surgery team is available appears safe. Fracture-related infection principles demand stable fixation that preserves bone biology, and the authors advise leaving spare screw holes or using the shortest adequate plate at the first stage to preserve options for reconstruction. Surgeons must also consider adjacent prosthetic joints, since metachronous infection of a same-side knee replacement has been reported in up to 20 percent of cases.

The interval between stages must be individualized, balancing the risk of septic failure against premature reimplantation compromising fracture healing. The team generally targets a window of roughly six weeks without an antibiotic-free interval, extended when fracture healing needs more time, and weighs wound status, C-reactive protein trends, spacer tolerance, and acetabular erosion. Conceptually, they treat the second stage as a single-stage exchange of the spacer, replacing all components including the first-stage plate, reasoning that organisms introduced during the long first procedure may not have been covered by targeted therapy, and that plate exchange is straightforward once the fracture is reduced and partially healed. The authors acknowledge the limits of their evidence: three heterogeneous patients, no control group, and a framework grounded in expert opinion. They call on large musculoskeletal infection centers to build prospective databases and on international societies to forge consensus algorithms. For now, their framework offers surgeons confronting this rare collision of broken bone and entrenched biofilm a tested, reproducible path through it.

Subject of Research: Two-stage surgical management of periprosthetic femoral fractures around chronically infected total hip arthroplasties

Article Title: Periprosthetic fractures around chronically infected total hip arthroplasties: a case series and pragmatic two-stage treatment framework

Article References: Vles, G. F., Metsemakers, W.-J., Aerden, L., Geurts, J., Borens, O., & Ghijselings, S. (2026). Periprosthetic fractures around chronically infected total hip arthroplasties: a case series and pragmatic two-stage treatment framework. Journal of Bone and Joint Infection, 11(4), 547-554. https://doi.org/10.5194/jbji-11-547-2026

Image Credits: AI Generated

DOI: 10.5194/jbji-11-547-2026

Keywords: periprosthetic fracture, periprosthetic joint infection, total hip arthroplasty, two-stage revision, antibiotic-loaded cement spacer, biofilm, fracture-related infection, septic loosening, revision stem, orthopaedic surgery, case series, debridement

Fracture-related infection, often abbreviated FRI, occurs when bacteria colonize the site of a broken bone, frequently around the plates, screws, or nails used to stabilize the fracture. The condition is estimated to affect roughly one to two percent of closed fractures, but the risk climbs dramatically in severe open injuries, exceeding thirty percent in Gustilo-Anderson type III open fractures depending on the anatomical site and injury severity. Treating these infections demands meticulously staged surgical protocols, prolonged hospitalization, and extended courses of antimicrobial therapy, all aimed simultaneously at eradicating the infection and restoring the biomechanical integrity of the skeleton. Reported eradication rates range widely, from twenty-nine to eighty-seven percent, and treatment failure can leave patients with irreversible functional compromise or even amputation.

The human toll of this complication extends well beyond the operating theatre. Traumatic injury alone can provoke adverse psychological outcomes, but the superimposition of a bone infection amplifies those effects through prolonged immobility, treatment uncertainty, and financially destabilizing periods of work incapacity. Infection recurrence portends intensified morbidity, extended therapy, and a profound deterioration in quality of life. Yet until now, the long-term effects of FRI on quality of life and mental health had remained murky, scattered across studies that used different instruments, definitions, and follow-up periods.

To bring order to this fragmented literature, the Regensburg team conducted a search compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, scanning PubMed, Web of Science, and Google Scholar for studies published between 2010 and August 2025. The initial search identified 7,808 articles, which the researchers whittled down through systematic screening to fifteen studies meeting strict inclusion criteria: adult patients with FRI, more than five participants, validated quality-of-life instruments, and a minimum follow-up of twelve months. Methodological quality was appraised using the Methodological Index for Non-Randomised Studies, known as MINORS, and risk of bias was assessed with the ROBINS-I framework, with discrepancies resolved through consensus meetings.

What the quality assessment revealed was a field built on shaky foundations. The evidence base was dominated by retrospective cohort studies, with no study achieving level I evidence, the gold standard of randomized trials. Studies achieved on average only 66.4 percent of the maximum MINORS score, and the average loss to follow-up was nearly twenty percent, ranging as high as 57.3 percent in one study. Ten of the fifteen studies carried a moderate risk of bias, three a high risk, and only two a low risk, with confounding identified as the principal source of bias because retrospective designs rarely fully account for factors that shape outcomes.

The quantitative findings nonetheless paint a coherent picture. In a meta-analysis of three studies covering 125 patients tracked before and after surgery, the physical component score of the SF-36 and SF-12 questionnaires rose by an average of 5.81 points at twelve months or more, an improvement that did not reach statistical significance. The mental component score rose by 3.86 points, also non-significant. More striking were the pooled long-term estimates drawn from seven studies comprising 262 patients: a mean physical component score of 38.9 and a mean mental component score of 51.2. When compared against normative data from the United States general population, where the mean physical score sits at 49.22, the FRI patients’ physical quality of life was significantly reduced, while the difference in mental quality of life was not statistically significant.

The psychological analysis added a troubling dimension. Three studies assessing 118 patients with the ICD-10-based Symptom Rating questionnaire, or ISR, found that the weighted mean depression score reached 1.08, crossing the cut-off value for a mild psychological symptom burden, a finding the researchers call caseness. The total ISR score of 0.68 also surpassed the caseness threshold, and sensitivity analyses confirmed that the depressive symptom finding was robust to the removal of any single study. Anxiety, compulsive, eating, and somatoform symptom scores, by contrast, remained below clinical thresholds, suggesting the psychological burden concentrates specifically in the depressive domain.

The authors are careful to caution against over-interpretation. Heterogeneity across the pooled studies was extreme, with the I-squared statistic reaching approximately 85.7 percent for the physical component score and a staggering 97.8 percent for the mental component score, indicating that study-specific, clinical, and methodological factors strongly influence observed outcomes. The pooled estimates, the researchers argue, should be read as descriptive reference benchmarks rather than precise predictions. Moreover, the depression findings cannot be attributed to infection itself, because the analysis lacked an appropriately matched control group of patients with comparable fractures, trauma exposure, or chronic conditions. It remains unclear whether the observed symptoms reflect the effects of the infection or the broader consequences of severe musculoskeletal injury and prolonged treatment.

Another complication is that the studies span more than fifteen years, a period during which the conceptual understanding and diagnostic framework of FRI evolved considerably. International consensus on a standardized definition of the condition emerged only recently, and earlier investigations often relied on less-standardized criteria, injecting further variability into the evidence base. Most cohorts also originated from German healthcare systems while the normative comparison data came from the United States, a mismatch the authors note is softened by previous work showing broad agreement between German and American SF-36 reference values, but which may still color the observed differences.

Perhaps the most clinically resonant insight emerges from the longitudinal data: successful eradication of infection does not inevitably restore patient-reported health. While two studies reported improved quality of life after treatment, the largest cohort actually demonstrated a decline following surgery, a discrepancy that underscores how the surgical battle against infection and the patient’s subjective recovery can diverge. The authors call for prospective, properly blinded studies using standardized FRI definitions, validated quality-of-life instruments, longitudinal follow-up, integrated psychological assessment, and carefully selected control groups to clarify whether the observed impairments arise primarily from the infection, the severe trauma, the surgical treatment, or the cumulative burden of recovery. In the meantime, they suggest, regular psychological screening of FRI patients deserves a place in routine follow-up care, because the wounds this complication leaves behind are not always visible on an X-ray.

Subject of Research: Long-term quality of life and depressive symptoms after fracture-related infection treatment

Article Title: Investigating long-term quality of life and depressive symptoms following fracture-related infection: a systematic review with meta-analysis of heterogeneous evidence

Article References: Betker, J. A., Walter, N., Rupp, M., Baertl, S., & Alt, V. (2026). Investigating long-term quality of life and depressive symptoms following fracture-related infection: a systematic review with meta-analysis of heterogeneous evidence. Journal of Bone and Joint Infection, 11(5), 569-577. https://doi.org/10.5194/jbji-11-569-2026

Image Credits: AI Generated

DOI: 10.5194/jbji-11-569-2026

Keywords: fracture-related infection, quality of life, depression, systematic review, meta-analysis, orthopaedic surgery, osteomyelitis, patient-reported outcomes, SF-36, mental health, trauma surgery, psychological screening

The research, published in Global Surgical Education, the Journal of the Association for Surgical Education, took a phenomenological approach, interviewing ten orthopaedic surgeons at a training hospital who had each used 3D printed models on between three and twelve cases. The team transcribed in-depth, semi-structured interviews and analysed them inductively using ATLAS.ti software, with three researchers coding independently before comparing and refining themes through an iterative process. Two main themes emerged from the data: the perceived benefits of working with printed models, and surgeons’ attitudes toward the technology itself.

The technical backdrop is important. Traditional pre-operative planning in orthopaedics relies on visual interpretation of X-rays, computed tomography and magnetic resonance imaging scans, essentially flat images that the surgeon must mentally translate into three-dimensional anatomy. Yet orthopaedic surgery is fundamentally a discipline of touch. Surgeons depend on haptic perception, the combination of tactile feedback from contact and kinesthetic feedback about how objects move and respond to pressure. When a surgeon must integrate visual information with an imagined sense of touch, the brain’s working memory, the limited-capacity system that holds and manipulates short-term information, can become overloaded, a phenomenon described in education research as cognitive load.

This is where the printed models appear to make their most profound contribution. Every surgeon in the study reported that holding a physical model of the patient’s anatomy positively influenced their preparation. Most described the model as an adjunct to image interpretation, revealing information that was not clearly visible on scans. Several described literally grasping the pathology, with one spine surgeon noting it was far easier to get to grips with exactly what a deformity involved when holding it in hand. A foot and ankle surgeon even placed a model of a deformed foot on the floor to assess how the forefoot related to the ground, a proxy that directly informed the goal of achieving a plantigrade, flat-standing foot.

Beyond perception, the models enabled genuine rehearsal. Several participants reported physically practising a procedure more than once before surgery, trialling different strategies and implant sizes against the patient’s native anatomy. For others, simply handling the model was enough to finalise a plan, with one upper limb surgeon describing how holding the glenoid allowed a physical model to form in the mind. Three of the ten surgeons also found the models valuable for communicating complex pathology to team members and patients, in every case linked to the difficulty of verbalising three-dimensional deformities in words alone.

The benefits carried into the operating theatre. Surgeons consistently described increased confidence and a sense of déjà vu when the real procedure matched the rehearsed one, with one paediatric orthopaedic surgeon calling the combination of mental and physical rehearsal a game changer. Some explicitly reported decreased cognitive load and reduced stress during operations, alongside perceived decreases in theatre time and increases in surgical accuracy, though the researchers caution these impressions may be subjective. Several surgeons used sterilised models inside the theatre as haptic maps, feeling their way through unusual anatomy when visibility was limited, while others described the models as guard rails that helped them detect unintended deviations from the surgical plan early.

The study also surfaced a compelling idea about how the technology might shift surgical practice. The authors suggest that planning with a printed model moves critical decision-making points from the stressful intra-operative environment into the calmer pre-operative phase, reducing the cognitive load a surgeon carries in theatre. For junior surgeons, those critical moments arise even in routine cases; for veterans, they arise only with unfamiliar, highly complex pathology. Notably, seven of the ten surgeons anticipated shorter theatre times and improved accuracy, yet nobody mentioned reductions in blood loss, fluoroscopic use or hospital stay, the objective outcomes that dominate the quantitative literature, hinting that the technology’s most immediate value may be cognitive rather than physiological.

Attitudes toward the technology were strongly positive and forward-looking. Surgeons frequently discussed how models could be modified to make rehearsal more realistic, such as using dual-material printing with elastic connectors to mimic ligaments holding bone fragments together. Most expected the technology to develop further and expressed intentions to proactively engage with it. Several voiced concern that over-regulation could price medical 3D printing out of everyday practice, arguing that a low-cost, do-it-yourself approach should be protected so that models can be made for almost every patient. Two participants said they would even postpone complex surgeries to allow time for a model to be manufactured, and one regretted not doing exactly that after feeling lost during a difficult case.

The findings also carry implications for surgical training. Participants widely viewed the models as a valuable tool for accelerating competence without patient harm, with one spine surgeon predicting that young surgeons would reach proficiency faster without being de-skilled. Others argued the technology raises the bar for the entire field, expanding the scope of what can be operated on competently in millimetre-and-degree measurable outcomes. The recurring overlap between discussions of training and of experienced surgeons preparing for novel cases underscores, the authors note, that surgical practice is a continuous embodied process punctuated by increasingly complicated challenges.

The study has limitations, including its small sample, coverage of only a few orthopaedic sub-specialties and a single-centre setting in a developing country, and the researchers observed that different sub-specialties use models differently, with spine surgeons favouring haptic maps and arthroplasty surgeons trialling implants. Still, the message is clear: as 3D printing becomes cheaper and more accessible, its perceived benefits among surgeons are overwhelmingly cognitive and educational, moving decision-making earlier, lightening mental load in theatre and potentially compressing the long apprenticeship of surgical experience. The authors call for future research linking these perceived benefits to established models of cognitive load and fatigue, and ultimately to measurable patient outcomes.

Subject of Research: Surgeons' experiences and perceived benefits of using 3D printed anatomical models for orthopaedic pre-operative planning and training

Article Title: Orthopaedic surgeons using 3D printed models to prepare for surgery: a qualitative investigation

Article References: Venter, R. G., Vogel, L., Visser, M., & Rabie, S. (2026). Orthopaedic surgeons using 3D printed models to prepare for surgery: a qualitative investigation. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 180. https://doi.org/10.1007/s44186-026-00587-3

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00587-3

Keywords: 3D printing, orthopaedic surgery, pre-operative planning, surgical training, cognitive load, haptic perception, working memory, anatomical models, qualitative research, patient-specific models, surgical education, Orthopaedic

The study, published in Global Surgical Education, the journal of the Association for Surgical Education, examined supernumerary registrars (SNRs) in orthopaedic surgery at UCT. SNRs are non-South African medical practitioners who undertake postgraduate training, research, and clinical work at South African universities. The program was first piloted in 1996 at the Nelson Mandela School of Medicine at the University of KwaZulu-Natal and has since been adopted by universities across the country. It was designed specifically for doctors from countries, particularly in Africa, where postgraduate specialist training programs are limited or entirely absent.

The premise is simple but ambitious: SNRs enroll in the same Master of Medicine (MMed) degree as their South African counterparts, sit the same examinations set by the Colleges of Medicine of South Africa, and are expected to function at the same academic and clinical capacity. They manage orthopaedic emergencies and elective conditions in outpatient clinics, operating theatres, and after-hours emergency settings. Crucially, however, they occupy positions outside the standard registrar quotas, making them an additional resource rather than a replacement. They are not paid by the South African government; instead, they are sponsored by their home governments, non-governmental organizations, or themselves, covering living expenses, MMed fees, and annual tuition. This arrangement has led some to describe SNRs as the ‘unsung heroes’ of the South African healthcare system, contributing to an under-resourced environment for more than 25 years at no cost to the state.

Despite this long history, no formal evaluation of the program’s impact had ever been conducted. The UCT team, led by Nqaba Mancotywa, Nicholas Kruger, and Sithombo Maqungo, set out to change that. Their cross-sectional study surveyed current registrars and registrar alumni attached to UCT’s Division of Orthopaedic Surgery, collecting data on demographics, research output, academic progression, operating theatre involvement, and career paths after graduation. Ethical approval was obtained from the UCT Human Research Ethics Committee, and data were drawn from participant surveys alongside a prospectively maintained departmental database logging every surgical procedure and the role of each surgeon involved.

The response was striking. Of 45 invited participants, 40 responded, an 89 percent response rate, comprising eight current SNRs, 13 South African registrars (SARs), 11 supernumerary alumni, and eight South African registrar alumni. All current SNRs came from Sub-Saharan African countries, and most had completed their undergraduate training there. Among alumni, six were from Sub-Saharan countries and five from North Africa. The researchers then compared the two groups across three domains: academic performance, clinical exposure, and post-graduation trajectory.

Academically, the picture was one of parity. SNRs and SARs showed similar publication productivity, with SARs slightly ahead overall, though SARs tended to publish more in local journals while SNRs leaned toward international outlets. Both groups entered the program with prior research experience, and the majority completed their MMed research projects within their training time. Most registrars in both groups passed the Fellowship of the College of Orthopaedic Surgeons of South Africa (FCOrth(SA)) primary and intermediate examinations on their first attempt, despite markedly different undergraduate backgrounds. The authors describe this as encouraging evidence that academic support is being delivered equitably across the two groups.

The clinical picture was far less balanced. As primary surgeons, SNRs averaged 232 theatre appearances compared with 482 for SARs, meaning local registrars logged nearly 50 percent more operative exposure. Only one SNR in the sample exceeded the average SAR’s theatre count, while 94 percent of SARs surpassed the average SNR. The gap persisted across assistant roles: as first assistants, SNRs averaged 123 appearances against 194 for SARs, and as second assistants, 21 against 60. Although the gap narrowed as training years progressed, it never closed to equivalence. Even the least experienced Year 2 South African registrar had nearly twice the theatre experience of the least experienced Year 2 supernumerary.

The researchers trace this discrepancy to the structure of entry pathways rather than to ability alone. South African registrars must pass FCS(SA) primary and intermediate examinations before applying, then rotate through a structured Medical Officer program in Cape Town’s level 2 hospitals, where they are mentored, upskilled, and assessed by orthopaedic consultants before joining the Groote Schuur Hospital trauma service. SNRs, by contrast, are selected mainly on the basis of health professional registration and curriculum vitae, with no standardized way to validate skills acquired in distant, variable training systems. On occasion, arriving SNRs were found to have limited basic surgical skills despite their enthusiasm, placing them at a disadvantage from day one. The department responds with personalized mentorship, pairing new SNRs with senior trauma registrars, and sometimes stationing them in the Trauma and Emergency Unit to assess their skills before full integration, measures that can delay academic progression and strain four-year sponsorship windows. Previous studies have also reported that some supernumeraries felt unprioritized in rotation scheduling and cited experiences of xenophobia and unequal academic support.

Where graduates end up may be the program’s most important metric, and here UCT performs well. Most supernumerary alumni returned to their countries of origin, with only a quarter relocating to high-income countries abroad and two remaining in South Africa. This contrasts with earlier findings at the KwaZulu-Natal program, where many SNRs expressed no intention of returning home, though it aligns with earlier UCT research showing high retention of Sub-Saharan surgical trainees within Africa. More than half of the supernumerary alumni now practice in the public or state sector, compared with only a quarter of South African alumni, and two hold leadership roles as heads of department or clinical units. The Botswana model offers a glimpse of the program’s evolution: trainees complete part of their training as supernumeraries in South Africa, then return home to finish under the University of Botswana, receiving CMSA specialist certification while being registered with the Botswana Health Professionals Council, a hybrid structure that structurally guarantees return.

The authors conclude that the program largely achieves its founding purpose, producing academically and clinically capable specialists equipped for service in their home countries, but they caution that changes may be needed to bridge the early-training gap between SNRs and SARs, and that the program remains vulnerable to misuse. Research output declined equally in both groups after graduation, likely reflecting a shift from training toward income generation in systems where academic positions are scarce. The team calls for further studies across UCT’s broader Faculty of Health Sciences and a qualitative follow-up examining registrars’ lived experiences and the oversight of the program. In a world where international medical graduates are typically expected to migrate permanently and finance their own training in host countries, South Africa’s return-home model stands alone, and this first formal audit suggests that, with targeted reforms to early operative exposure, it could become a template for surgical capacity building across the African continent.

Subject of Research: Evaluation of the clinical and academic impact of supernumerary orthopaedic registrar training at the University of Cape Town compared with South African registrars

Article Title: Supernumerary registrars in orthopaedics at the University of Cape Town: a review of their training locally and in their countries of origin, compared to South African registrars

Article References: Mancotywa, N., Kruger, N., & Maqungo, S. (2026). Supernumerary registrars in orthopaedics at the University of Cape Town: a review of their training locally and in their countries of origin, compared to South African registrars. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 161. https://doi.org/10.1007/s44186-026-00561-z

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00561-z

Keywords: supernumerary registrars, orthopaedic surgery, University of Cape Town, surgical training, South Africa, medical education, Sub-Saharan Africa, MMed degree, theatre exposure, registrar alumni, surgical capacity building, CMSA examinations