The role of low-grade infection in the pathogenesis of apparently aseptic tibial shaft nonunion

Hackl, Simon; Keppler, Lena; Rüden, Christian von; Friederichs, Jan; Perl, Mario; Hierholzer, Christian

doi:10.1016/j.injury.2021.08.014

Cited by 27 publications

(17 citation statements)

References 29 publications

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“…Although reports on low-grade or low-virulence infection in the orthopaedic trauma literature are limited, 2 studies have found a higher incidence of occult infection in patients presenting without fistula or sinus. Hackl et al 8 studied 88 patients with tibial shaft nonunion, finding that 44% of these patients had a positive culture; however, the end point of this study was a positive culture and not the diagnosis of infection based on the FRI criteria. In a second study examining the number of tissue samples needed to accurately diagnose FRI, the incidence of infection without confirmatory signs on presentation was 26%; however, this study included patients with suspected biofilm and did not consider elevated laboratory markers or other suggestive signs to be indicative of infection.…”

Section: Discussionmentioning

confidence: 77%

“…5 Concurrently, recent literature has also described occult infections in the setting of nonunion as infections that slow progression of healing but do not present with signs of infection. [6][7][8] These reports cite low-grade or low-virulence infections such as coagulase-negative Staphylococcus (CoNS) and Cutibacterium acnes (C. acnes) that present without clinical or laboratory signs of infection but still slow fracture healing. 8 Originally believed to be contaminants, the concept of low-virulence infections originated from the total joint arthroplasty literature where these organisms are now considered to be true pathogens.…”

Section: Introductionmentioning

confidence: 99%

“…[6][7][8] These reports cite low-grade or low-virulence infections such as coagulase-negative Staphylococcus (CoNS) and Cutibacterium acnes (C. acnes) that present without clinical or laboratory signs of infection but still slow fracture healing. 8 Originally believed to be contaminants, the concept of low-virulence infections originated from the total joint arthroplasty literature where these organisms are now considered to be true pathogens. 9 Failing to identify these pathogens can potentially alter the treatment of fracture nonunion.…”

Section: Introductionmentioning

confidence: 99%

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Diagnosis of Occult Infection Using Fracture-Related Infection Criteria at the Time of Nonunion Repair

Shah

Simpson

Frederickson

et al. 2023

Journal of Orthopaedic Trauma

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Section: Discussionmentioning

confidence: 77%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Diagnosis of Occult Infection Using Fracture-Related Infection Criteria at the Time of Nonunion Repair

Shah

Simpson

Frederickson

et al. 2023

Journal of Orthopaedic Trauma

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“…LCP and bone grafting were applied in these patients. This method was not used for those suspected of low-grade infectious nonunion [ 28 ]. A positive outcome of this study was that LCP fixation ensured good alignment of nonunion ends after debridement of deformities or synovial pseudarthrosis.…”

Section: Discussionmentioning

confidence: 99%

A novel bone graft technique combined with plating for aseptic recalcitrant long bone nonunion

Jiang

Wang

Huang

et al. 2022

BMC Musculoskelet Disord

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Background To evaluate the outcomes and efficacy of a new technique of autogenous iliac crest bone grafting combined with locking compression plate (LCP) vertical fixation for aseptic recalcitrant long bone nonunion. Methods From July 2010 to September 2020, 36 aseptic recalcitrant long bone nonunions were treated with a bone-forming channel technique and internal LCP fixation. All the patients had received one or more failed treatments. The injury mechanism, nonunion type and duration, and prior treatments were recorded pre-operation. The routine treatment process included nonunion area exposure, previous implant removal, sclerotic bone debridement, LCP fixation, bone-forming channel creation, and iliac bone grafting, and a second LCP fixation when required. At follow-up, X-ray images were obtained to assess bone healing and implant failure. Visual analog scale (VAS), fracture site stability, limb function, activity, muscle strength, limb length, and complications were recorded. Results A total of 34 patients (24 males and 10 females) were finally enrolled, with a mean age of 49.8 ± 12.3 years. At a mean follow-up of 35.6 ± 22.0 months, 32 patients displayed bone union, with a healing rate of 94.1% and mean union time of 6.8 ± 2.4 months. The VAS score was 0.7 ± 1 at the final follow-up. The functional results showed that 19 patients were excellent, 11 patients were good, 2 patients were poor, and 2 patients did not heal. Conclusion Bone-forming channel technique combined with LCP vertical fixation is an excellent option to treat recalcitrant long bone nonunion. Level of evidence Therapeutic Level IV.

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“…One essential criterion for the treatment of fracture nonunion is the presence or absence of bacterial infection. However, differentiating between septic and aseptic nonunion is challenging, especially when dealing with low-grade infections which are difficult to distinguish from aseptic nonunion [ 1 , 2 ]. Low-grade infections are often caused by biofilm-forming bacteria, which may remain undetected in tissue cultures (TCs) and erroneously lead to aseptic diagnoses [ 2 – 4 ].…”

Section: Introductionmentioning

confidence: 99%

The value of sonication in the differential diagnosis of septic and aseptic femoral and tibial shaft nonunion in comparison to conventional tissue culture and histopathology: a prospective multicenter clinical study

Trenkwalder,

Erichsen,

Weisemann

et al. 2023

J Orthop Traumatol

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Background Septic and aseptic nonunion require different therapeutic strategies. However, differential diagnosis is challenging, as low-grade infections and biofilm-bound bacteria often remain undetected. Therefore, the examination of biofilm on implants by sonication and the evaluation of its value for differentiating between femoral or tibial shaft septic and aseptic nonunion in comparison to tissue culture and histopathology was the focus of this study. Materials and methods Osteosynthesis material for sonication and tissue samples for long-term culture and histopathologic examination from 53 patients with aseptic nonunion, 42 with septic nonunion and 32 with regular healed fractures were obtained during surgery. Sonication fluid was concentrated by membrane filtration and colony-forming units (CFU) were quantified after aerobic and anaerobic incubation. CFU cut-off values for differentiating between septic and aseptic nonunion or regular healers were determined by receiver operating characteristic analysis. The performances of the different diagnostic methods were calculated using cross-tabulation. Results The cut-off value for differentiating between septic and aseptic nonunion was ≥ 13.6 CFU/10 ml sonication fluid. With a sensitivity of 52% and a specificity of 93%, the diagnostic performance of membrane filtration was lower than that of tissue culture (69%, 96%) but higher than that of histopathology (14%, 87%). Considering two criteria for infection diagnosis, the sensitivity was similar for one tissue culture with the same pathogen in broth-cultured sonication fluid and two positive tissue cultures (55%). The combination of tissue culture and membrane-filtrated sonication fluid had a sensitivity of 50%, which increased up to 62% when using a lower CFU cut-off determined from regular healers. Furthermore, membrane filtration demonstrated a significantly higher polymicrobial detection rate compared to tissue culture and sonication fluid broth culture. Conclusions Our findings support a multimodal approach for the differential diagnosis of nonunion, with sonication demonstrating substantial usefulness. Level of Evidence: Level 2 Trial registration DRKS00014657 (date of registration: 2018/04/26)

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The role of low-grade infection in the pathogenesis of apparently aseptic tibial shaft nonunion

Cited by 27 publications

References 29 publications

Diagnosis of Occult Infection Using Fracture-Related Infection Criteria at the Time of Nonunion Repair

Diagnosis of Occult Infection Using Fracture-Related Infection Criteria at the Time of Nonunion Repair

A novel bone graft technique combined with plating for aseptic recalcitrant long bone nonunion

The value of sonication in the differential diagnosis of septic and aseptic femoral and tibial shaft nonunion in comparison to conventional tissue culture and histopathology: a prospective multicenter clinical study

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