Aim: To describe the clinical characteristics, management strategies, microbiology, and outcomes of patients treated for upper limb bone infection at a tertiary referral centre, including longitudinal patient-reported health status.

Methods: A cohort study of patients treated for upper limb bone infection identified between 2013 and 2024 in a single specialist bone infection centre. Bones included were clavicle, humerus, radius, and ulnar. Demographic, clinical, microbiological, and surgical data were collected, including infection aetiology, BACH classification, treatment strategy, and follow-up. The primary outcome was treatment failure. Secondary outcomes included EQ-5D-5L utility score. Longitudinal EQ-5D-5L scores were summarised using normalised trapezoidal area under the curve (AUC).

Results: A total of 148 patients met the inclusion criteria for infection (mean age 50.4years SD 17.6 years). Infection followed fracture in 88 patients (59.5%), haematogenous osteomyelitis in 35 (23.6%), following orthopaedic procedures in 15 (10.1%), and 12 were contiguous focus (8.1%). Patients were referred from a mean distance of 78.5km (SD 50.5km) from their home. Forty-eight cases (32.4%) were classified as BACH-uncomplicated, 84 (56.8%) BACH-complex, and 16 (10.8%) BACH-limited options. 

Overall, 133 patients underwent surgery, with a standardized protocol of pre-operative optimization, deep tissue sampling, debridement, stabilization and skin closure, usually in a single stage procedure. Patients had initial empiric antibiotics after sampling with definitive therapy decided after culture and usually within 7 days of surgery. Baseline EQ-5D-5L utility was similar in operative and non-operative groups (0.649, IQR 0.35-0.778 vs 0.548, IQR 0.157-0.9). In surgical cases, 122 (91.7%) received local antibiotics, and 15 (11.3%) required flap coverage. Staphylococcus aureus was the commonest isolate (39.8%); 23 (17.3%) infections were polymicrobial and Cutibacterium acnes was isolated in only 11 (8.3%) patients, despite prolonged culture in an automated blood culture system (BD BACTEC™).

In 16/133 (12.0%) patients, surgical treatment failed at a median follow-up of 1.6 years (IQR 0.93-2.6) Treatment failure was more frequent in BACH-complex than BACH-uncomplicated cases (17.9% vs 2.1%, p<0.001). Patients with treatment failure had worse longitudinal normalised EQ-5D-5L scores than those without failure (0.554 vs 0.774, p=0.036), and BACH-complex cases had worse scores than BACH-uncomplicated cases (0.691 vs 0.930, p<0.001).

Conclusion: Upper limb bone infection is a complex condition associated with substantial treatment burden and a 12% treatment failure rate. The BACH classification accurately predicted clinical failure and patient-reported health status. Successful treatment produced substantial improvement in quality of life, close to age-matched population norms.