Diagnosing Fracture-Related Infection: Current Concepts and Recommendations

Govaert, Geertje A M; Kuehl, Richard; Atkins, Bridget L.; Trampuž, Andrej; Morgenstern, Mario; Obremskey, William T.; Verhofstad, Michael H J; McNally, Martin; Metsemakers, Willem‐Jan

doi:10.1097/bot.0000000000001614

Cited by 238 publications

(246 citation statements)

References 74 publications

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“…Recently, an internationally accepted definition, including diagnostic criteria, was developed for FRI [3]. These diagnostic criteria were updated in a more recent publication [4]. Two levels of certainty around diagnostic features were defined.…”

Section: Diagnosis Of Frimentioning

confidence: 99%

“…1. Suggestive signs should motivate the medical team to further investigate the possibility of the presence of an FRI [3,4]. Confirmatory and suggestive criteria for the diagnosis of FRI are listed in Table 1.…”

Section: Diagnosis Of Frimentioning

confidence: 99%

“…A detailed overview of the available diagnostic criteria is presented in affiliated articles of the FRI consensus group [3,4].…”

Section: Diagnosis Of Frimentioning

confidence: 99%

“…Confirmation of infection is achieved by culture of microorganisms from deep tissue samples, metal implants or histopathological evaluation of deep tissue [4]. All cases of FRI require tissue sampling.…”

Section: Tissue Samplingmentioning

confidence: 99%

See 3 more Smart Citations

General treatment principles for fracture-related infection: recommendations from an international expert group

Metsemakers

Morgenstern

Senneville

et al. 2019

Arch Orthop Trauma Surg

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198

176

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Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients' short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group. Level of evidence: Level V.

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Section: Diagnosis Of Frimentioning

confidence: 99%

Section: Diagnosis Of Frimentioning

confidence: 99%

“…A detailed overview of the available diagnostic criteria is presented in affiliated articles of the FRI consensus group [3,4].…”

Section: Diagnosis Of Frimentioning

confidence: 99%

Section: Tissue Samplingmentioning

confidence: 99%

See 2 more Smart Citations

General treatment principles for fracture-related infection: recommendations from an international expert group

Metsemakers

Morgenstern

Senneville

et al. 2019

Arch Orthop Trauma Surg

Self Cite

198

176

View full text Add to dashboard Cite

show abstract

“…The LV1 loading plot shows the major contributors to positive LV1 values (collagen only group) and negative LV1 values (collagen + infection group) ( Figure 6C) and little to no improvement in infection-related patient outcomes over the past several decades (36). In particular, for fracture-associated infections, there is currently no consensus on diagnostic criteria and therefore very few protocols for diagnosis and treatment (37). S. aureus causes the majority of bone infection cases and is known for its immune evasion mechanisms and manipulation of humoral and adaptive immunity.…”

mentioning

confidence: 99%

Development of Systemic Immune Dysregulation in a Rat Trauma Model with Biomaterial-Associated Infection

Vantucci

Ahn

Schenker

et al. 2020

Preprint

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Orthopedic biomaterial-associated infections remain a large clinical challenge, particularly with open fractures and segmental bone loss. Invasion and colonization of bacteria within immuneprivileged canalicular networks of the bone can lead to local, indolent infections that can persist for years without symptoms before eventual catastrophic hardware failure. Host immunity is essential for bacterial clearance and an appropriate healing response, and recent evidence has suggested an association between orthopedic trauma and systemic immune dysregulation and immunosuppression. However, the impact of a local infection on this systemic immune response and subsequent effects on the local response is poorly understood and has not been a major focus for addressing orthopedic injuries and infections. Therefore, this study utilized a model of orthopedic biomaterial-associated infection to investigate the effects of infection on the longterm immune response. Here, despite persistence of a local, indolent infection lacking outward symptoms, there was still evidence of long-term immune dysregulation with systemic increases in MDSCs and decreases in T cells compared to non-infected trauma. Further, the trauma only group exhibited a regulated and coordinated systemic cytokine response, which was not present in the infected trauma group. Locally, the infection group had attenuated macrophage infiltration in the local soft tissue compared to the non-infected group. Our results demonstrate widespread impacts of a localized orthopedic infection on the systemic and local immune responses.Characterization of the immune response to orthopedic biomaterial-associated infection may identify key targets for immunotherapies that could optimize both regenerative and antibiotic interventions, ultimately improving outcomes for these patients.

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