Fracture-related infection

Baertl, Susanne; Metsemakers, Willem‐Jan; Morgenstern, Mario; Alt, Volker; Richards, R. Geoff; Moriarty, T. Fintan; Young, Katie

doi:10.1302/2046-3758.106.bjr-2021-0167.r1

Cited by 31 publications

(22 citation statements)

References 11 publications

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“…Good outcomes in fracture care can be adversely affected by fracture-related infection (FRI), leading to non-union and, occasionally, limb loss [ 1 ]. This presents a major burden for patients and healthcare systems around the world [ 2 , 3 ].…”

Section: Introductionmentioning

confidence: 99%

What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

et al. 2022

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This international, multi-center study investigated the effect of individual components of surgery on the clinical outcomes of patients treated for fracture-related infection (FRI). All patients with surgically treated FRIs, confirmed by the FRI consensus definition, were included. Data were collected on demographics, time from injury to FRI surgery, soft tissue reconstruction, stabilization and systemic and local anti-microbial therapy. Patients were followed up for a minimum of one year. In total, 433 patients were treated with a mean age of 49.7 years (17–84). The mean follow-up time was 26 months (range 12–72). The eradication of infection was successful in 86.4% of all cases and 86.0% of unhealed infected fractures were healed at the final review. In total, 3.3% required amputation. The outcome was not dependent on age, BMI, the presence of metalwork or time from injury (recurrence rate 16.5% in FRI treated at 1–10 weeks after injury; 13.1% at 11–52 weeks; 12.1% at >52 weeks: p = 0.52). The debridement and retention of a stable implant (DAIR) had a failure rate of 21.4%; implant exchange to a new internal fixation had a failure rate of 12.5%; and conversion to external fixation had a failure rate of 10.3% (adjusted hazard ratio (aHR) DAIR vs. Ext Fix 2.377; 95% C.I. 0.96–5.731). Tibial FRI treated with a free flap was successful in 92.1% of cases and in 80.4% of cases without a free flap (HR 0.38; 95% C.I. 0.14–1.0), while the use of NPWT was associated with higher recurrence rates (HR 3.473; 95% C.I. 1.852–6.512). The implantation of local antibiotics reduced the recurrence from 18.7% to 10.0% (HR 0.48; 95% C.I. 0.29–0.81). The successful treatment of FRI was multi-factorial. These data suggested that treatment decisions should not be based on time from injury alone, as other factors also affected the outcome. Further work to determine the best indications for DAIR, free flap reconstruction and local antibiotics is warranted.

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Section: Introductionmentioning

confidence: 99%

What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

et al. 2022

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“…Treatment of open tibial fractures includes appropriate and prompt antibiotic treatment (within three hours), 22 , 23 surgical debridement, irrigation, bone stabilization, and fast and sufficient soft-tissue coverage. 24 When considering the high infection rates, the diversity of the encountered bacteria and the devastating consequences, e.g. risk of amputation, for patients suffering from open fracture-related infections, sufficient broad-spectrum antibiotic prophylaxis is important.…”

Section: Discussionmentioning

confidence: 99%

Tibial bone and soft-tissue concentrations following combination therapy with vancomycin and meropenem – evaluated by microdialysis in a porcine model

Vittrup

Hanberg

Knudsen

et al. 2022

Bone & Joint Research

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Aims Prompt and sufficient broad-spectrum empirical antibiotic treatment is key to preventing infection following open tibial fractures. Succeeding co-administration, we dynamically assessed the time for which vancomycin and meropenem concentrations were above relevant epidemiological cut-off (ECOFF) minimal inhibitory concentrations (T > MIC) in tibial compartments for the bacteria most frequently encountered in open fractures. Low and high MIC targets were applied: 1 and 4 µg/ml for vancomycin, and 0.125 and 2 µg/ml for meropenem. Methods Eight pigs received a single dose of 1,000 mg vancomycin and 1,000 mg meropenem simultaneously over 100 minutes and 10 minutes, respectively. Microdialysis catheters were placed for sampling over eight hours in tibial cancellous bone, cortical bone, and adjacent subcutaneous adipose tissue. Venous blood samples were collected as references. Results Across the targeted ECOFF values, vancomycin displayed longer T > MIC in all the investigated compartments in comparison to meropenem. For both drugs, cortical bone exhibited the shortest T > MIC. For the low MIC targets and across compartments, mean T > MIC ranged between 208 and 449 minutes (46% to 100%) for vancomycin and between 189 and 406 minutes (42% to 90%) for meropenem. For the high MIC targets, mean T > MIC ranged between 30 and 446 minutes (7% to 99%) for vancomycin and between 45 and 181 minutes (10% to 40%) for meropenem. Conclusion The differences in the T > MIC between the low and high targets illustrate how the interpretation of these results is highly susceptible to the defined MIC target. To encompass any trauma, contamination, or individual tissue differences, a more aggressive dosing approach may be considered to achieve longer T > MIC in all the exposed tissues, and thereby lower the risk of acquiring an infection after open tibial fractures. Cite this article: Bone Joint Res 2022;11(2):112–120.

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“…The final diagnosis was based on clinical and intraoperative findings, and histopathological and microbiological examinations (five periprosthetic tissue/fluid samples). 20 The specific criteria are shown in Table II. Statistical analysis.…”

Section: Periprosthetic Joint Infection (≥ 1 Positive Criteria) Asept...mentioning

confidence: 99%

Application of ⁶⁸Ga-citrate PET/CT for differentiating periprosthetic joint infection from aseptic loosening after joint replacement surgery

Zeng

Xiao-mi

et al. 2022

Bone & Joint Research

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Aims We aimed to evaluate the utility of 68Ga-citrate positron emission tomography (PET)/CT in the differentiation of periprosthetic joint infection (PJI) and aseptic loosening (AL), and compare it with 99mTc-methylene bisphosphonates (99mTc-MDP) bone scan. Methods We studied 39 patients with suspected PJI or AL. These patients underwent 68Ga-citrate PET/CT, 99mTc-MDP three-phase bone scan and single-photon emission CT (SPECT)/CT. PET/CT was performed at ten minutes and 60 minutes after injection, respectively. Images were evaluated by three nuclear medicine doctors based on: 1) visual analysis of the three methods based on tracer uptake model, and PET images attenuation-corrected with CT and those not attenuation-corrected with CT were analyzed, respectively; and 2) semi-quantitative analysis of PET/CT: maximum standardized uptake value (SUVmax) of lesions, SUVmax of the lesion/SUVmean of the normal bone, and SUVmax of the lesion/SUVmean of the normal muscle. The final diagnosis was based on the clinical and intraoperative findings, and histopathological and microbiological examinations. Results Overall, 23 and 16 patients were diagnosed with PJI and AL, respectively. The sensitivity and specificity of three-phase bone scan and SPECT/CT were 100% and 62.5%, 82.6%, and 100%, respectively. Attenuation correction (AC) at 60 minutes and non-AC at 60 minutes of PET/CT had the same highest sensitivity and specificity (91.3% and 100%), and AC at 60 minutes combined with SPECT/CT could improve the diagnostic efficiency (sensitivity = 95.7%). Diagnostic efficacy of the SUVmax was low (area under the curve (AUC) of ten minutes and 60 minutes was 0.814 and 0.806, respectively), and SUVmax of the lesion/SUVmean of the normal bone at 60 minutes was the best semi-quantitative parameter (AUC = 0.969). Conclusion 68Ga-citrate showed the potential to differentiate PJI from AL, and visual analysis based on uptake pattern of tracer was reliable. The visual analysis method of AC at 60 minutes, combined with 99mTc-MDP SPECT/CT, could improve the sensitivity from 91.3% to 95.7%. In addition, a major limitation of our study was that it had a limited sample size, and more detailed studies with a larger sample size are warranted. Cite this article: Bone Joint Res 2022;11(6):398–408.

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Fracture-related infection

Cited by 31 publications

References 11 publications

What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

Tibial bone and soft-tissue concentrations following combination therapy with vancomycin and meropenem – evaluated by microdialysis in a porcine model

Application of ⁶⁸Ga-citrate PET/CT for differentiating periprosthetic joint infection from aseptic loosening after joint replacement surgery

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Fracture-related infection

Cited by 31 publications

References 11 publications

What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

Tibial bone and soft-tissue concentrations following combination therapy with vancomycin and meropenem – evaluated by microdialysis in a porcine model

Application of 68Ga-citrate PET/CT for differentiating periprosthetic joint infection from aseptic loosening after joint replacement surgery

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Application of ⁶⁸Ga-citrate PET/CT for differentiating periprosthetic joint infection from aseptic loosening after joint replacement surgery