Bone infection: a clinical priority for clinicians, scientists and educators

Abstract

Bone infection has received increasing attention in recent years as one of the main outstanding clinical problems in orthopaedic-trauma surgery that has not been successfully addressed. In fact, infection may develop across a spectrum of patient types regardless of the level of perioperative management, including antibiotic prophylaxis. Some of the main unknown factors that may be involved, and the main targets for future intervention, include more accurate and less invasive diagnostic options, more thorough and accurate debridement protocols, and more potent and targeted antimicrobials. The underlying biology dominates the clinical management of bone infections, with features such as biofilm formation, osteolysis and vascularisation being particularly influential. Based on the persistence of this problem, an improved understanding of the basic biology is deemed necessary to enable innovation in the field. Furthermore, from the clinical side, better evidence, documentation and outreach will be required to translate these innovations to the patient. This review presents the findings and progress of the AO Trauma Clinical Priority Program on the topic of bone infection.

The surgical management of fracture-related infection. Surgical strategy selection and the need for early surgical intervention

“… 28 Invasion of the osteocyte lacuno-canalicular network may be another key factor in bacterial persistence through evasion of antibiotics and the immune response. 29 These “hubs” may serve as the nidus of continued bacterial invasion. Finally, abscesses, for example in the medullary cavity, may also serve as bacterial reservoirs offering protection against antibiotics.…”

“…Surgery remains one of the cornerstones of the treatment of FRI. 22 All surgical approaches have one important element in common, a judicious well-planned debridement with removal of all dead tissues and acquisition of deep tissue biopsies for microbiology and histopathology. 29 Local and systemic antibiotics are valuable adjuncts, but alone are unlikely to ensure eradication of infection. 37 Following the debridement and sampling, the fracture fixation needs to be addressed.…”

Review of immunological plasma markers for longitudinal analysis of inflammation and infection in rat models

“…Certain plasma markers, such as C-reactive protein (CRP) 13 and white blood cell (WBC) counts 14 are well accepted as clinical indicators for different conditions of inflammation and infection but are not reliable in certain orthopedic cases. 14,15 Many clinicians will use multiple plasma markers, such as the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, which includes blood CRP, WBC, hemoglobin, sodium, creatine, and glucose levels, to help determine the need for a revision surgery; however, this score does not accurately differentiate necrotizing fasciitis and cellulitis. 16 Similarly, recent clinical research has explored biomarkers indicative of pathogen-specific response to infection to improve diagnosis and prognosis using proteomic mapping, specifically for Staphylococcus aureus (S. aureus) bacteremia 17,18 and osteomyelitis.…”