1
|
Metsemakers WJ, Moriarty TF, Morgenstern M, Marais L, Onsea J, O'Toole RV, Depypere M, Obremskey WT, Verhofstad MHJ, McNally M, Morshed S, Wouthuyzen-Bakker M, Zalavras C. The global burden of fracture-related infection: can we do better? THE LANCET. INFECTIOUS DISEASES 2024; 24:e386-e393. [PMID: 38042164 DOI: 10.1016/s1473-3099(23)00503-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 12/04/2023]
Abstract
Fracture-related infection is a major complication related to musculoskeletal injuries that not only has important clinical consequences, but also a substantial socioeconomic impact. Although fracture-related infection is one of the oldest disease entities known to mankind, it has only recently been defined and, therefore, its global burden is still largely unknown. In this Personal View, we describe the origin of the term fracture-related infection, present the available data on its global impact, and discuss important aspects regarding its prevention and management that could lead to improved outcomes in both high-resource and low-resource settings. We also highlight the need for health-care systems to be adequately compensated for the high cost of human resources (trained staff) and well-equipped facilities required to adequately care for these complex patients. Our aim is to increase awareness among clinicians and policy makers that fracture-related infection is a disease entity that deserves prioritisation in terms of research, with the goal to standardise treatment and improve patient outcomes on a global scale.
Collapse
Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - T Fintan Moriarty
- AO Research Institute Davos, Davos, Switzerland; Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Leonard Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Martin McNally
- The Bone Infection Unit, Oxford University Hospitals, Oxford, UK
| | - Saam Morshed
- Department of Orthopaedic Surgery and Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
2
|
Su Y, Li D, Du B, Li Z, Lu Y, Xu Y, Wang Q, Li Z, Ren C, Ma T. Analysis of risk factors for the recurrence of osteomyelitis of the limb after treatment with antibiotic-loaded calcium sulfate and autologous bone graft. Front Bioeng Biotechnol 2024; 12:1368818. [PMID: 38807650 PMCID: PMC11130418 DOI: 10.3389/fbioe.2024.1368818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/01/2024] [Indexed: 05/30/2024] Open
Abstract
Objective We aimed to evaluate the efficacy of antibiotic-loaded calcium sulfate combined with autologous iliac bone transplantation in the treatment of limb-localized osteomyelitis (Cierny-Mader type III) and analyze the causes and risk factors associated with infection recurrence. Methods Clinical data of 163 patients with localized osteomyelitis of the extremities treated with antibiotic-loaded calcium sulfate combined with autologous iliac bone transplantation in Xi'an Honghui Hospital from January 2017 to December 2022 were retrospectively analyzed. All patients were diagnosed with localized osteomyelitis through clinical examination and treated with antibiotic-loaded calcium sulfate combined with autologous iliac bone. Based on the infection recurrence status, the patients were divided into the recurrence group and the non-recurrence group. The clinical data of the two groups were compared using univariate analysis. Subsequently, the distinct datasets were included in the binary logistic regression analysis to determine the risk and protective factors. Results This study included 163 eligible patients, with an average age of 51.0 years (standard deviation: 14.9). After 12 months of follow-up, 25 patients (15.3%) experienced infection recurrence and were included in the recurrence group; the remaining 138 patients were included in the non-recurrence group. Among the 25 patients with recurrent infection, 20 required reoperation, four received antibiotic treatment alone, and one refused further treatment. Univariate analysis showed that education level, smoking, hypoproteinemia, open injury-related infection, and combined flap surgery were associated with infection recurrence (p < 0.05). Logistic regression analysis showed that open injury-related infection (odds ratio [OR] = 35.698; 95% confidence interval [CI]: 5.997-212.495; p < 0.001) and combined flap surgery (OR = 41.408; 95% CI: 5.806-295.343; p < 0.001) were independent risk factors for infection recurrence. Meanwhile, high education level (OR = 0.009; 95% CI: 0.001-0.061; p < 0.001) was a protective factor for infection recurrence. Conclusion Antibiotic-loaded calcium sulfate combined with autologous iliac bone transplantation is an effective method for treating limb-localized osteomyelitis. Patients without previous combined flap surgery and non-open injury-related infections have a relatively low probability of recurrence of infection after treatment with this surgical method. Additionally, patients with a history of smoking and hypoproteinemia should pay attention to preventing the recurrence of infection after operation. Providing additional guidance and support, particularly in patients with lower education levels and compliance, could contribute to the reduction of infection recurrence.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Cheng Ren
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Teng Ma
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| |
Collapse
|
3
|
Merrell LA, Adams JC, Kingery MT, Ganta A, Konda SR, Egol KA. Fracture related infection (FRI) of the upper extremity correlates with poor bone and soft tissue healing. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1201-1207. [PMID: 38010445 DOI: 10.1007/s00590-023-03750-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/25/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the specific course and complication profile following the development of FRI in the upper extremity. METHODS An IRB-approved retrospective review was conducted on a consecutive series of operatively managed patients within an academic medical center between 1/2010 and 6/2022. Included patients met the following criteria: (1) upper extremity fracture definitively treated with internal fixation (2) development of criteria for suggestive or confirmatory FRI (as per the FRI Consensus Group) and (3) age ≥ 18 years. Baseline demographics, medical history, injury information, infection characteristics, hospital quality measures, and outcomes were recorded. A 3:1 propensity-matched control cohort of patients without FRI was obtained using the same dataset. Univariable analysis was performed to compare the outcomes (rate of nonunion, time to bone healing, need for soft tissue coverage, patient reported joint stiffness at final follow-up) of the FRI vs Non-FRI cohorts. RESULTS Of 2827 patients treated operatively for an upper extremity fracture, 43 (1.53%) met criteria for suggestive of confirmatory FRI. The successful propensity match (43 FRI, 129 Non-FRI) revealed no differences in demographics, baseline health status, or fracture location. FRI patients underwent more reoperations (p < 0.001), experienced an increased rate of removal of hardware (p < 0.001), and were admitted more frequently following index operation (p < 0.001). The FRI cohort had higher rates of fracture nonunion (p = 0.003), and a prolonged mean time to bone healing in months (8.37 ± 7.29 FRI vs. 4.14 ± 5.75 Non-FRI, p < 0.001). Additionally, the FRI cohort had a greater need for soft tissue coverage throughout their post-operative fracture treatment (p = 0.014). While there was no difference in eventual bone healing (p = 0.250), FRI patients experienced a higher incidence of affected joint stiffness at final follow-up (p < 0.001). CONCLUSION Patients who develop an FRI of the upper extremity undergo more procedures and experience increased complications throughout their treatment, specifically increased joint stiffness. Despite this, ultimate outcome profiles are similar between patients who experience FRI and those who do not following operative repair of an upper extremity fracture. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Lauren A Merrell
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Medical Center, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Jack C Adams
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Medical Center, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Matthew T Kingery
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Medical Center, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Abhishek Ganta
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Medical Center, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Sanjit R Konda
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Medical Center, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Kenneth A Egol
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Medical Center, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA.
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA.
| |
Collapse
|
4
|
Li M, Sun G, Cui J, Lou Q. Risk factors for surgical site infection after closed proximal humerus fractures. Int Wound J 2023; 21:e14515. [PMID: 38009983 PMCID: PMC10898375 DOI: 10.1111/iwj.14515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 11/29/2023] Open
Abstract
Proximal humerus fractures are common in clinical practice, and there are relatively a few studies on postoperative incision infections of such fractures. The purpose of this study was to explore the risk factors for surgical site infection (SSI) after internal fixation in patients with closed proximal humerus fractures. Patients with closed proximal humerus fractures who underwent surgery from January 2016 to January 2022 were retrospectively analysed. Cases with superficial or deep infections within 3 months after surgery were in the infection group and the remaining cases were in the non-infection group. The types of pathogenic bacteria in the infection group were analysed. The potential risk factors for SSI in all patients were recorded: (1) patient-related factors: gender, age, body mass index (BMI), smoking, comorbidities; (2) trauma-related factors: mechanism of injury, Injury Severity Score, visual analogue scale, fracture type, soft tissue condition and combined dislocation; (3) laboratory-related indexes: haemoglobin, albumin; (4) surgery-related factors: time from injury to surgery, American Society of Anesthesiologists anaesthesia classification, surgical time, fixation mode, intraoperative blood loss, suture method, bone graft and postoperative drainage. The risk factors for the occurrence of SSI were analysed using univariate analysis and multivariate logistic regression. The incidence of SSI was 15.7%. The most common bacterium in the infection group was Staphylococcus aureus. High BMI (p = 0.033), smoking (p = 0.030), an increase in mean time from injury to definitive surgery (p = 0.013), and prolonged surgical time (p = 0.044) were independent risk factors for the development of SSI after closed proximal humeral fractures. In patients with closed proximal humerus fractures, weight loss, perioperative smoking cessation, avoidance of delayed surgery, and shorter surgical time may be beneficial in reducing the incidence of SSI.
Collapse
Affiliation(s)
- Ming Li
- Department of OrthopaedicsThe First People's Hospital of JiashanJiaxingZhejiangPeople's Republic of China
| | - Guang‐chen Sun
- Department of OrthopaedicsThe First People's Hospital of JiashanJiaxingZhejiangPeople's Republic of China
| | - Jun Cui
- Department of OrthopaedicsThe First People's Hospital of JiashanJiaxingZhejiangPeople's Republic of China
| | - Qi‐liang Lou
- Department of OrthopaedicsThe First People's Hospital of JiashanJiaxingZhejiangPeople's Republic of China
| |
Collapse
|
5
|
Herbosa CG, Esper GW, Nwakoby EV, Leucht P, Konda SR, Tejwani NC, Egol KA. Screws Alone for Acute Lisfranc Injuries Fixed Without Arthrodesis: A Better "Value" Than Plating in the Short Term. J Foot Ankle Surg 2023; 62:768-773. [PMID: 36966966 DOI: 10.1053/j.jfas.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 03/15/2023] [Accepted: 03/19/2023] [Indexed: 05/12/2023]
Abstract
This study compares outcomes of patients with Lisfranc injuries treated with screw only fixation constructs to those treated with dorsal plate and screw constructs. Seventy patients who underwent surgical treatment for acute Lisfranc injury without arthrodesis and minimum 6-month (mean >1-year) follow-up were identified. Demographics, surgical information, and radiographic imaging were reviewed. Cost data were compared. The primary outcome measure was the American Orthopedic Foot and Ankle Surgery (AOFAS) midfoot score. Univariate analysis through independent sample t tests, Mann-Whitney U, and chi-squared compared the populations. Twenty-three (33%) patients were treated with plate constructs and 47 (67%) with screw only fixation. The plate group was older (49 ± 18 vs 40 ± 16 years, p = .029). More screw constructs treated isolated medial column injuries compared to plate constructs (92% vs 65%, p = .006). At latest follow-up (mean 14 ± 13 months), all tarsometatarsal joints were aligned. There was no difference in AOFAS midfoot scores. Plate patients experienced longer operations (131 ± 70 vs 75 ± 31 minutes, p < .001) and tourniquet time (101 ± 41 vs 69 ± 25 minutes, p = .001). Plate constructs were more expensive than screw ($2.3X ± $2.3X vs $X ± $0.4X, p < .001) ($X is the mean cost of screws alone). Plate patients had a higher incidence of wound complications (13% vs 0%, p = .012). Treatment of Lisfranc fracture dislocation injuries with screws only demonstrated a higher value procedure as similar outcomes were found amidst lower implant costs. Screw only fixation required a shorter operative and tourniquet time with less frequent wound complications. Screw only fixations proved mechanically sound enough to achieve goals of repair without inferior outcomes.
Collapse
Affiliation(s)
- Christopher G Herbosa
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Garrett W Esper
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Ekenedilichukwu V Nwakoby
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Philipp Leucht
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Sanjit R Konda
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Nirmal C Tejwani
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Kenneth A Egol
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY.
| |
Collapse
|
6
|
Solasz S, Merrell L, Ganta A, Konda S, Egol KA. Factors Associated With the Development of a Confirmed Fracture-Related Infection. J Orthop Trauma 2023; 37:e361-e367. [PMID: 37587567 DOI: 10.1097/bot.0000000000002615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES To identify factors associated with the development of fracture-related infection (FRI) in patients who have undergone operative fixation of their fracture. DESIGN Retrospective study. SETTING Academic medical center. PATIENTS/PARTICIPANTS Patients with peripheral extremity long-bone fractures and shoulder and pelvic girdle fractures who underwent operative repair. This included patients who had undergone fixation inside and outside of our institution. INTERVENTION Chi-square, Fisher exact testing, analysis of variance (ANOVA), and t tests were used for analysis of data, as appropriate. Binomial logistic regression analysis was performed to determine risk factors of FRI. MAIN OUTCOME MEASUREMENTS Demographics, fracture location, injury mechanism, open wound status, and wound complication type. RESULTS One hundred ninety-three patients comprised the FRI cohort. Of those with confirmed signs of FRI, 36 (18.7%) had wound breakdown to bone or implant, 120 (62.1%) had a sinus track, and 170 patients (88.1%) had the confirmed presence of microorganisms in deep tissue samples obtained during operative intervention. Factors associated with development of an FRI were as follows: higher BMI; being of Black and Hispanic race; higher American Society of Anesthesiologists class; history of tobacco, alcohol, and drug use; and fractures of the lower extremity (foot, tibia, and femur/pelvis). The results of binary logistic regression demonstrated that treatment at an urban level I trauma center and drug use positively predicted the development of FRI. CONCLUSION Our results demonstrate that higher BMI; being of Black or Hispanic race; higher American Society of Anesthesiologists; history of tobacco, alcohol, and drug use; and fractures of the foot, tibia, and femur/pelvis are all factors associated with development of FRI. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Sara Solasz
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | | | | | | | | |
Collapse
|
7
|
Hussain SA, Walters S, Ahluwalia AK, Trompeter A. Fracture-related infections. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37646543 DOI: 10.12968/hmed.2022.0545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Fracture-related infection is a serious complication which can occur following musculoskeletal injury and is associated with significant morbidity. These complications can be challenging to recognise, and experts have provided a clearer definition of fracture-related infection to help with the diagnosis and detection of these infections. This system includes clinical, radiological and laboratory-based diagnostic features which are either confirmatory or suggestive of fracture-related infection. Treatment requires a multifaceted approach with multidisciplinary involvement, and generally a combination of surgical techniques and prolonged antibiotics, the timing and choice of which should be optimised. This article provides an evidence-based review of the British Orthopaedic Association Standards for Trauma for the diagnosis and management of fracture-related infections.
Collapse
Affiliation(s)
| | - Samuel Walters
- Orthopaedic Trauma/Limb Reconstruction Unit, St George's University Hospital, London, UK
| | - Aashish K Ahluwalia
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
| | - Alex Trompeter
- Orthopaedic Trauma/Limb Reconstruction Unit, St George's University Hospital, London, UK
| |
Collapse
|
8
|
Yong TM, Rackard FA, Dutton LK, Sparks MB, Harris MB, Gitajn IL. Analyzing risk factors for treatment failure in fracture-related infection. Arch Orthop Trauma Surg 2023; 143:1387-1392. [PMID: 35043253 DOI: 10.1007/s00402-021-04277-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 11/24/2021] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Fracture-related infection (FRI) represents a challenging clinical scenario. Limited evidence exists regarding treatment failure after initial management of FRI. The objective of our investigation was to determine incidence and risk factors for treatment failure in FRI. MATERIALS AND METHODS We conducted a retrospective review of patients treated for FRI between 2011 and 2015 at three level 1 trauma centers. One hundred and thirty-four patients treated for FRI were identified. Demographic and clinical variables were extracted from the medical record. Treatment failure was defined as the need for repeat debridement or surgical revision seven or more days after the presumed final procedure for infection treatment. Univariate comparisons were conducted between patients who experienced treatment failure and those who did not. Multivariable logistic regression was conducted to identify independent associations with treatment failure. RESULTS Of the 134 FRI patients, 51 (38.1%) experienced treatment failure. Patients who failed were more likely to have had an open injury (31% versus 17%; p = 0.05), to have undergone implant removal (p = 0.03), and additional index I&D procedures (3.3 versus 1.6; p < 0.001). Most culture results identified a single organism (62%), while 15% were culture negative. Treatment failure was more common in culture-negative infections (p = 0.08). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism associated with treatment failure (29%; p = 0.08). Multivariate regression demonstrated a statistically significant association between treatment failure and two or more irrigation and debridement (I&D) procedures (OR 13.22, 95% CI 4.77-36.62, p < 0.001) and culture-negative infection (OR 4.74, 95% CI 1.26-17.83, p = 0.02). CONCLUSIONS The rate of treatment failure following FRI continues to be high. Important risk factors associated with treatment failure include open fracture, implant removal, and multiple I&D procedures. While MRSA remains common, culture-negative infection represents a novel risk factor for failure, suggesting aggressive treatment of clinically diagnosed cases remains critical even without positive culture data. LEVEL OF EVIDENCE Retrospective cohort study; Level III.
Collapse
Affiliation(s)
- Taylor M Yong
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | | | - Lauren K Dutton
- Department of Orthopedics, Naval Hospital, Jacksonville, Jacksonville, FL, USA
| | - Michael B Sparks
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ida L Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| |
Collapse
|
9
|
Sundheepkumar V, Saravanan R, Krishnan B. INFECTIOUS COMPLICATIONS IN COMPOUND MANDIBULAR FRACTURES UNDERGOING A DELAYED SURGICAL INTERVENTION - A PROSPECTIVE OBSERVATIONAL STUDY. Br J Oral Maxillofac Surg 2023; 61:302-308. [PMID: 37061417 DOI: 10.1016/j.bjoms.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/10/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023]
Abstract
The aim of this prospective study was to analyse if a delay in the time from injury to definitive surgical intervention of open reduction and internal fixation (ORIF) of compound mandibular fractures predisposed to an increase in postoperative infectious complications. ORIF beyond 72 hours from injury was considered to be delayed intervention. Postoperative surgical site infections (SSI) and non-infectious complications (NIC) were recorded. The Mann-Whitney U test was used to compare the delay in ORIF with SSI. The chi squared test/Fisher's exact test was used to find the association of the infectious complication status with predetermined risk factors. Eighty-three patients underwent a delayed ORIF with a median (range) of 8 (4-19) days. SSI was documented in eight patients (9.6%) and could be managed as outpatient medical and surgical intervention. Two patients needed repeat surgical intervention due to non-union of the fracture. The median (range) time to ORIF was 6.5 (5-12) days in patients who developed SSI; the Mann-Whitney U test did not show a statistically significant association between delayed ORIF and SSI (p = 0.7). The univariate analysis did not establish a significant relationship between SSI and predetermined risk factors. The delay to definitive surgical intervention was not observed to be an independent attributing factor in postoperative infectious complications of compound mandibular fractures.
Collapse
|
10
|
Vanvelk N, Van Lieshout E, Onsea J, Sliepen J, Govaert G, IJpma F, Depypere M, Ferguson J, McNally M, Obremskey W, Zalavras C, Verhofstad M, Metsemakers WJ. Diagnosis of fracture-related infection in patients without clinical confirmatory criteria: an international retrospective cohort study. J Bone Jt Infect 2023; 8:133-142. [PMID: 37123499 PMCID: PMC10134751 DOI: 10.5194/jbji-8-133-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background: fracture-related infection (FRI) remains a serious complication in orthopedic trauma. To standardize daily clinical practice, a consensus definition was established, based on confirmatory and suggestive criteria. In the presence of clinical confirmatory criteria, the diagnosis of an FRI is evident, and treatment can be started. However, if these criteria are absent, the decision to surgically collect deep tissue cultures can only be based on suggestive criteria. The primary study aim was to characterize the subpopulation of FRI patients presenting without clinical confirmatory criteria (fistula, sinus, wound breakdown, purulent wound drainage or presence of pus during surgery). The secondary aims were to describe the prevalence of the diagnostic criteria for FRI and present the microbiological characteristics, both for the entire FRI population. Methods: a multicenter, retrospective cohort study was performed, reporting the demographic, clinical and microbiological characteristics of 609 patients (with 613 fractures) who were treated for FRI based on the recommendations of a multidisciplinary team. Patients were divided in three groups, including the total population and two subgroups of patients presenting with or without clinical confirmatory criteria. Results: clinical and microbiological confirmatory criteria were present in 77 % and 87 % of the included fractures, respectively. Of patients, 23 % presented without clinical confirmatory criteria, and they mostly displayed one (31 %) or two (23 %) suggestive clinical criteria (redness, swelling, warmth, pain, fever, new-onset joint effusion, persisting/increasing/new-onset wound drainage). The prevalence of any suggestive clinical, radiological or laboratory criteria in this subgroup was 85 %, 55 % and 97 %, respectively. Most infections were monomicrobial (64 %) and caused by Staphylococcus aureus. Conclusion: clinical confirmatory criteria were absent in 23 % of the FRIs. In these cases, the decision to operatively collect deep tissue cultures was based on clinical, radiological and laboratory suggestive criteria. The combined use of these criteria should guide physicians in the management pathway of FRI. Further research is needed to provide guidelines on the decision to proceed with surgery when only these suggestive criteria are present.
Collapse
Affiliation(s)
- Niels Vanvelk
- Trauma Research Unit, Department of Surgery, Erasmus MC, University
Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Esther M. M. Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University
Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven,
Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen,
Groningen, the Netherlands
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht,
Utrecht, the Netherlands
| | - Frank F. A. IJpma
- Department of Trauma Surgery, University Medical Centre Groningen,
Groningen, the Netherlands
| | - Melissa Depypere
- Department of laboratory medicine, University Hospitals Leuven,
Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory
of Clinical Bacteriology and Mycology, KU Leuven, Leuven, Belgium
| | - Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford
University Hospitals, Oxford, UK
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford
University Hospitals, Oxford, UK
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt
University Medical Center, Nashville, Tennessee, USA
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine,
University of Southern California, Los Angeles, USA
| | - Michael H. J. Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University
Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven,
Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| |
Collapse
|
11
|
He SY, Yu B, Jiang N. Current Concepts of Fracture-Related Infection. Int J Clin Pract 2023; 2023:4839701. [PMID: 37153693 PMCID: PMC10154639 DOI: 10.1155/2023/4839701] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/24/2023] [Accepted: 04/08/2023] [Indexed: 05/10/2023] Open
Abstract
Currently, fracture-related infection (FRI) still represents great challenges in front of orthopaedic surgeons, despite great advances that have been achieved regarding its diagnosis and treatment. Although both FRI and prosthetic joint infection (PJI) belong to osteoarticular infections and share similarities, FRI displays unique characteristics. Diagnosis of FRI is sometimes difficult owing to the nonspecific symptoms, and treatment is usually tricky, with a high risk of infection recurrence. In addition, the long disease course is associated with a significantly elevated risk of disability, both physically and psychologically. Moreover, such a disorder still poses heavy economic burdens to the patients, both personally and socially. Therefore, early diagnosis and reasonable treatment are the key issues for increasing the cure rate, decreasing the risks of infection relapse and disability, and improving the life quality and prognosis of the patients. In this review, we summarized the present concepts regarding the definition, epidemiology, diagnosis, and treatment of FRI.
Collapse
Affiliation(s)
- Si-ying He
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
| | - Bin Yu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
| | - Nan Jiang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
| |
Collapse
|
12
|
Effect of Local Antibiotic Prophylaxis on Postoperative Deep Infection in Fracture Surgery: A Systematic Review and Meta-Analysis. J Orthop Trauma 2023; 37:e28-e35. [PMID: 36084224 DOI: 10.1097/bot.0000000000002487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Despite the use of systemic antibiotic prophylaxis, postoperative infection after fracture surgery remains an issue. The purpose of this systematic review and meta-analysis was to evaluate the effect of locally applied antibiotics on deep infection in fracture surgery in both the open and closed fractures. DATA SOURCES A comprehensive search of MEDLINE, Embase, and PubMed was performed from the date of inception to April 15, 2021, and included studies in all languages. STUDY SELECTION Cohort studies were eligible if they investigated the effect on the infection rate of local antibiotic prophylaxis on deep infection after fracture surgery. DATA EXTRACTION This study was conducted according to the Cochrane Handbook for Systematic Reviews and reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials and the Methodological Index for Nonrandomized Studies tool where applicable. DATA SYNTHESIS An inverse variance random-effects model was the primary analysis model because of the anticipated diversity in the evaluated populations. Univariate models were used when a single outcome was of interest. CONCLUSIONS The risk of deep infection was significantly reduced when local antibiotics were applied compared with the control group receiving systemic prophylaxis only. This beneficial effect was observed in open fractures but failed to reach statistical significance in closed fractures. This meta-analysis suggests that there may be a significant risk reduction in deep infection rate after fracture surgery when local antibiotics are added to standard systemic prophylaxis, particularly in open fractures. Further high-powered Level I studies are needed to support these findings. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
13
|
Prada C, Bengoa F, Bhandari M. The management of fracture related infections: What practices can be supported by high-level evidence? J Orthop Surg (Hong Kong) 2022; 30:10225536221119580. [PMID: 36545907 DOI: 10.1177/10225536221119580] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Fracture related infections (FRIs) are a disabling condition causing significant concern within the orthopaedic community. FRIs have a huge societal and economic burden leading to prolonged recovery times and the potential for becoming chronic conditions or being life-threatening. Despite its importance in our field, the surgical community has just recently agreed on a definition which, added to the lack of surgical trials assessing preventive and treatment interventions have limited our understanding and precipitated wide variations in surgeons' practice. This article aims to review the current practices that can be supported with high-quality evidence. Currently, we have a limited body of high-quality evidence on FRI prevention and treatment. A handful of measures have proven effective, such as the use of prophylactic antibiotics, the use of saline and low pressure as the preferred irrigation solution and the safety of delaying initial surgical débridement more than 6 hours without impacting infection rates for open fracture wounds débridement. Future multicentre trials, properly powered, will shed light on current areas of controversy regarding the benefit of different preoperative and perioperative factors for the prevention and treatment of FRIs. Higher quality evidence is needed to guide surgeons to offer an evidence-based approach to prevent FRI occurrence and to treat patients suffering from them.
Collapse
Affiliation(s)
- Carlos Prada
- Division of Orthopaedic Surgery, Department of Surgery, 3710McMaster University, Hamilton, Ontario, Canada
| | - Francisco Bengoa
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, 3710McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, 3710McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
14
|
Tas DB, Smeeing DPJ, Keizer J, Houwert RM, Emmink BL. Postoperative Complications of Minimally Invasive Intramedullary Nail Fixation Versus Plate Fixation for Distal Fibular Fractures in Elderly Patients: A Retrospective Double Cohort Study in a Geriatric Trauma Unit in the Netherlands. J Foot Ankle Surg 2022; 61:1170-1176. [PMID: 34802911 DOI: 10.1053/j.jfas.2021.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/12/2021] [Accepted: 10/11/2021] [Indexed: 02/03/2023]
Abstract
Intramedullary fixation using a fibular nail is a minimally invasive alternative to conventional plate fixation that provides superior biomechanical strength and allows immediate full weightbearing postoperatively. The study aim was to compare the postoperative complications of minimally invasive intramedullary fibular nail fixation to plate fixation for Lauge-Hansen supination external rotation type 4 (Weber B) fractures in patients aged 65 years or older treated in a single geriatric trauma unit in the Netherlands. A retrospective cohort study was performed including patients aged 65 years or older with a Lauge-Hansen supination external rotation type 4 (Weber B) fracture treated with either intramedullary fibular fixation or plate fixation between January 2017 and January 2019. A total number of 58 patients were included with a mean age of 73.9 years (range 65-95). The intramedullary fixation-cohort (n = 13) had a significantly higher mean age (82.5 vs 71.4 years, p = .002) and Charlson Co-morbidity Index (4.7 vs 3.6, p = .005) compared to the plate fixation-cohort (n = 45). The total number of postoperative complications was lower after intramedullary fixation (n = 2, 15%) compared to plate fixation (n = 15, 33%), although this relative difference was not significant (p = .307). All 2 complications observed after intramedullary fixation were wound infections demanding no debridement or implant removal. No implant related complications, hospital-acquired complications or mortality were observed after intramedullary fixation. Despite the higher mean age and co-morbidity status of patients treated with minimally invasive intramedullary fibular nailing, the total number of postoperative complications was lower after intramedullary fixation compared to plate fixation. This technique might be a promising alternative in selected patients.
Collapse
Affiliation(s)
- David B Tas
- Department of Trauma Surgery, Antonius Hospital, Utrecht, The Netherlands; Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | | | - Jort Keizer
- Department of Trauma Surgery, Antonius Hospital, Utrecht, The Netherlands
| | - Roderick M Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Utrecht Traumacenter, Utrecht, The Netherlands
| | - Benjamin L Emmink
- Department of Trauma Surgery, Gelre Hospital, Apeldoorn, The Netherlands
| |
Collapse
|
15
|
The State of Research in Fracture-Related Infection—A Bibliometric Analysis. Medicina (B Aires) 2022; 58:medicina58091170. [PMID: 36143847 PMCID: PMC9506014 DOI: 10.3390/medicina58091170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives: Fracture-related infection (FRI) is a challenging complication in trauma surgery. A consensus definition of FRI has only recently been published. Therefore, the purpose of this study was to evaluate the state of research related to FRI. Material and Methods: A systemic literature review was conducted on research on FRI published between 2017 and 2020. The Web of Science database was used, and a bibliometric analysis was performed. To provide robust evidence regarding the impact of publications, the behavior of publications in non-traditional dissemination channels was analyzed. For this, the Research Interest Score and the Altmetric Score were combined. The Research Interest Score was calculated from information extracted from ResearchGate, while Altmetric Score includes information from different websites and apps with a significant volume of traffic, such as Twitter. Results: A total of 131 published papers were identified. The most significant contribution came from the United States and European countries. The most relevant articles were published by the journal Injury—International Journal of the Care of the Injured. A positive correlation was observed between the number of citations and Research Interest Scores, whereas the number of citations and Altmetric Score showed no correlation. The social media platform most used by FRI researchers was Twitter. Conclusions: By evaluating the status of publications for FRI between 2017 and 2020, an upward trend in the number of publications was evident. This could be related to the increasing acceptance of the long-needed definition for FRI and the implications it carries for daily clinical practice.
Collapse
|
16
|
Duane TM, Sercy E, Banton KL, Blackwood B, Hamilton D, Hentzen A, Hatch M, Akinola K, Gordon J, Bar-Or D. Factors associated with delays in medical and surgical open facial fracture management. Trauma Surg Acute Care Open 2022; 7:e000952. [PMID: 36068845 PMCID: PMC9437730 DOI: 10.1136/tsaco-2022-000952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives Open fractures are at risk of infection because of exposure of bone and tissue to the environment. Facial fractures are often accompanied by other severe injuries, and therefore fracture management may be delayed until after stabilization. Previous studies in this area have examined timing of multiple facets of care but have tended to report on each in isolation (eg, antibiotic initiation). Methods This was a retrospective study of adult patients admitted to five trauma centers from January 1, 2017 to March 31, 2021 with open facial fractures. Variables collected included demographics, injury mechanism, details on facial and non-facial injuries, facial fracture management (irrigation and debridement (I&D), irrigation without debridement, open reduction internal fixation (ORIF), antibiotics), and other hospital events. The study hypothesized that the presence of serious non-facial injuries would be associated with delays in facial fracture management. The primary aims were to describe open facial fracture management practices and examine factors associated with early versus delayed fracture management. A secondary aim was to describe infection rates. Early treatment was defined as within 24 hours of arrival for I&D, irrigation without debridement, and ORIF and within 1 hour for antibiotics. Results A total of 256 patients were included. Twenty-seven percent had major trauma (Injury Severity Score ≥16). The presence of serious head injury/traumatic brain injury was associated with delayed I&D (ORearly=0.04, p<0.01), irrigation without debridement (ORearly=0.09, p<0.01), and ORIF (ORearly=0.10, p<0.01). Going to the OR within 24 hours was associated with early I&D (ORearly=377.26, p<0.01), irrigation without debridement (ORearly=13.54, p<0.01), and ORIF (ORearly=154.92, p<0.01). The infection rate was 4%. Conclusions In this examination of multiple aspects of open facial fracture management, serious injuries to non-facial regions led to delays in surgical fracture management, consistent with the study hypothesis. Level of evidence Level III, prognostic/epidemiological.
Collapse
Affiliation(s)
- Therese M Duane
- Trauma Services Department, Medical Center of Plano, Plano, Texas, USA
| | - Erica Sercy
- Trauma Research Department, Injury Outcomes Network, Englewood, Colorado, USA
| | - Kaysie L Banton
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado, USA
| | - Brian Blackwood
- Department of Orthopedic Surgery, St Anthony Hospital & Medical Campus, Lakewood, Colorado, USA
| | - David Hamilton
- Trauma Services Department, Penrose Hospital, Colorado Springs, Colorado, USA
| | - Andrew Hentzen
- Trauma Services Department, Wesley Medical Center, Wichita, Kansas, USA
| | - Matthew Hatch
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado, USA
| | - Kerrick Akinola
- Trauma Services Department, St Anthony Hospital & Medical Campus, Lakewood, Colorado, USA
| | - Jeffrey Gordon
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado, USA
| | - David Bar-Or
- Trauma Research Department, Injury Outcomes Network, Englewood, Colorado, USA
| |
Collapse
|
17
|
McNally M, Corrigan R, Sliepen J, Dudareva M, Rentenaar R, IJpma F, Atkins BL, Wouthuyzen-Bakker M, Govaert G. What Factors Affect Outcome in the Treatment of Fracture-Related Infection? Antibiotics (Basel) 2022; 11:antibiotics11070946. [PMID: 35884200 PMCID: PMC9312092 DOI: 10.3390/antibiotics11070946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 12/24/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
- Correspondence:
| | - Ruth Corrigan
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
- Nuffield Department of Clinical Laboratory Sciences, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands; (J.S.); (F.I.)
| | - Maria Dudareva
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
| | - Rob Rentenaar
- Department of Medical Microbiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Frank IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands; (J.S.); (F.I.)
| | - Bridget L. Atkins
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands;
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands;
| |
Collapse
|
18
|
Onsea J, Van Lieshout EMM, Zalavras C, Sliepen J, Depypere M, Noppe N, Ferguson J, Verhofstad MHJ, Govaert GAM, IJpma FFA, McNally MA, Metsemakers WJ. Validation of the diagnostic criteria of the consensus definition of fracture-related infection. Injury 2022; 53:1867-1879. [PMID: 35331479 DOI: 10.1016/j.injury.2022.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The recently developed fracture-related infection (FRI) consensus definition, which is based on specific diagnostic criteria, has not been fully validated in clinical studies. We aimed to determine the diagnostic performance of the criteria of the FRI consensus definition and evaluated the effect of the combination of certain suggestive and confirmatory criteria on the diagnostic performance. METHODS A multicenter, multi-national, retrospective cohort study was performed. Patients were subdivided into an FRI or a control group, according to the treatment they received and the recommendations from a multidisciplinary team ('intention to treat'). Exclusion criteria were patients with an FRI diagnosed outside the study period, patients younger than 18 years of age, patients with pathological fractures or patients with fractures of the skull, cervical, thoracic and lumbar spine. Minimum follow up for all patients was 18 months. RESULTS Overall, 637 patients underwent revision surgery for suspicion of FRI. Of these, 480 patients were diagnosed with FRI, treated accordingly, and included in the FRI group. The other 157 patients were included in the control group. The presence of at least one confirmatory sign was associated with a sensitivity of 97.5%, a specificity of 100% and a high discriminatory value (AUROC 0.99, p < 0.001). The presence of a clinical confirmatory criterion or, if not present, at least one positive culture was associated with the highest diagnostic performance (sensitivity: 98.6%, specificity: 100%, AUROC: 0.99 (p < 0.001)). In the subgroup of patients without clinical confirmatory signs at presentation, specificities of at least 95% were found for the clinical suggestive signs of fever, wound drainage, local warmth and redness. CONCLUSIONS The presence of at least one confirmatory criterion identifies the vast majority of patients with an FRI and was associated with an excellent diagnostic discriminatory value. Therefore, our study validates the confirmatory criteria of the FRI consensus definition. Infection is highly likely in case of the presence of a single positive culture with a virulent pathogen. When certain clinical suggestive signs (e.g., wound drainage) are observed (individually or in combination and even without a confirmatory criterion), it is more likely than not, that an infection is present.
Collapse
Affiliation(s)
- Jolien Onsea
- University Hospitals Leuven, Department of Trauma Surgery, Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Melissa Depypere
- University Hospitals Leuven, Department of laboratory medicine, Leuven, Belgium
| | - Nathalie Noppe
- University Hospitals Leuven, Department of radiology, Leuven, Belgium
| | - Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Michael H J Verhofstad
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geertje A M Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank F A IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium.
| |
Collapse
|
19
|
Duration of Perioperative Antibiotic Prophylaxis in Open Fractures: A Systematic Review and Critical Appraisal. Antibiotics (Basel) 2022; 11:antibiotics11030293. [PMID: 35326757 PMCID: PMC8944527 DOI: 10.3390/antibiotics11030293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 02/05/2023] Open
Abstract
Fracture-related infection (FRI) remains a serious complication in open fracture care. Adequate surgical treatment and perioperative antibiotic prophylaxis (PAP) are key factors influencing the outcome. However, data concerning the optimal duration of PAP is scarce. The aim of this systematic review was to provide an overview of current evidence on the association between PAP duration and FRI in open fractures. A comprehensive search on 13 January 2022, in Embase, Medline, Cochrane, Web of Science and Google Scholar revealed six articles. Most studies compared either 1 day versus 5 days of PAP or included a cut-off at 72 h. Although prolonged PAP was not beneficial in the majority of patients, the variety of antibiotic regimens, short follow-up periods and unclear description of outcome parameters were important limitations that were encountered in most studies. This systematic review demonstrates a lack of well-constructed studies investigating the effect of PAP duration on FRI. Based on the available studies, prolonged PAP does not appear to be beneficial in the prevention of FRI in open fractures. However, these results should be interpreted with caution since all included studies had limitations. Future randomized trials are necessary to answer this research question definitively.
Collapse
|
20
|
Zelle BA. CORR Insights®: Ninety-Day Follow-up Is Inadequate for Diagnosis of Fracture-related Infections in Patients with Open Fractures. Clin Orthop Relat Res 2022; 480:147-149. [PMID: 34463659 PMCID: PMC8673983 DOI: 10.1097/corr.0000000000001964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/11/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Boris A Zelle
- Professor, Vice Chair of Research, Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
| |
Collapse
|
21
|
Clausen JD, Mommsen P, Omar Pacha T, Winkelmann M, Krettek C, Omar M. [Management of fracture-related infections]. Unfallchirurg 2021; 125:41-49. [PMID: 34932139 DOI: 10.1007/s00113-021-01116-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 12/19/2022]
Abstract
Fracture-related infections (FRI) are a major challenge in orthopedic trauma surgery. The problems in the treatment of such infections are manifold. Especially in cases with insufficient fracture consolidation the treatment not only focusses on the eradication of the infection but also on the restoration of the osseous continuity. The extent of the accompanying soft tissue damage is of particular importance as reduced vascularization leads to impairments in fracture healing. Although acute infections are frequently easy to recognize, the symptoms of chronic infections can be unspecific and evade the diagnostic procedures. This fact makes the treatment of such infections complicated and sometimes necessitates an interdisciplinary approach. For this reason, the Fracture-related Infection Consensus Group developed an algorithm, which was first published in 2017 and revised in 2018 and 2020. The FRIs are biofilm-associated infections, so that the current guidelines follow the previously established treatment algorithms for periprosthetic infections. Despite the analogies to periprosthetic infections there are also differences in the treatment as the aspects of fracture healing and bone defect restoration represent determining factors in the treatment of FRI. This article presents the special features of FRI and the classification and guidelines for the treatment are discussed.
Collapse
Affiliation(s)
- Jan-Dierk Clausen
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Philipp Mommsen
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Tarek Omar Pacha
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Marcel Winkelmann
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Christian Krettek
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Mohamed Omar
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| |
Collapse
|
22
|
Rupp M, Bärtl S, Lang S, Walter N, Alt V. [Fracture-related infections after intramedullary nailing : Diagnostics and treatment]. Unfallchirurg 2021; 125:50-58. [PMID: 34923596 DOI: 10.1007/s00113-021-01117-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 11/29/2022]
Abstract
Intramedullary nailing is the treatment of choice for a large number of fractures requiring surgery. In cases of fracture-related infections (FRI) the treatment of nail infections requires special attention due to the closed situation of the osteosynthesis material in the intramedullary canal. This article gives an overview of the general principles and diagnostic criteria for FRI after nail fixation and discusses the treatment recommendations based on three case examples. In cases of acute implant infections, an implant-retaining procedure is principally possible for both periprosthetic joint infections and FRI; however, after intramedullary nailing the nail should also be exchanged in cases of acute nail infections as a sufficient debridement of the nail is impossible due to its intramedullary location. In chronic FRI after intramedullary nailing a one-stage or two-stage procedure can be followed. In cases of adequate soft tissue coverage, good fracture reduction and an expected bone healing without critical bony substance defects, a one-stage procedure with nail exchange should be preferred. If a chronic infection with soft tissue and bone defects develops after intramedullary nailing, a two-stage procedure analogous to the treatment of osteomyelitis should be considered. In this case a multidisciplinary team approach with specialists in plastic surgery, microbiology and infectious diseases is necessary. The use of local antibiotics and antimicrobial-coated implants is deemed to be advantageous.
Collapse
Affiliation(s)
- Markus Rupp
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Susanne Bärtl
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Siegmund Lang
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Nike Walter
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| |
Collapse
|
23
|
Wittauer M, Burch MA, McNally M, Vandendriessche T, Clauss M, Della Rocca GJ, Giannoudis PV, Metsemakers WJ, Morgenstern M. Definition of long-bone nonunion: A scoping review of prospective clinical trials to evaluate current practice. Injury 2021; 52:3200-3205. [PMID: 34531088 DOI: 10.1016/j.injury.2021.09.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/06/2021] [Indexed: 02/02/2023]
Abstract
AIM Although nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures. METHODS A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database. RESULTS Although 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months. CONCLUSION In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria.
Collapse
Affiliation(s)
- Matthias Wittauer
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland, Spitalstrasse 21, 4031 Basel, Switzerland; University of Basel, Petersplatz 1, 4001 Basel, Switzerland
| | - Marc-Antoine Burch
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland, Spitalstrasse 21, 4031 Basel, Switzerland; University of Basel, Petersplatz 1, 4001 Basel, Switzerland
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Windmill Rd, Oxford OX3 7LD, UK
| | - Thomas Vandendriessche
- KU Leuven Libraries - 2Bergen - Learning Centre Désiré Collen, Herestraat 49, 3000 Leuven, Belgium
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland, Spitalstrasse 21, 4031 Basel, Switzerland; University of Basel, Petersplatz 1, 4001 Basel, Switzerland
| | - Gregory J Della Rocca
- Department of Orthopaedic Surgery, University of Missouri, 1 Hospital Dr, Columbia, MO, 65201, USA
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS2 9JT, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Chapeltown Rd, Leeds LS7 4SA, UK
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland, Spitalstrasse 21, 4031 Basel, Switzerland; University of Basel, Petersplatz 1, 4001 Basel, Switzerland.
| |
Collapse
|
24
|
What is the diagnostic value of the Centers for Disease Control and Prevention criteria for surgical site infection in fracture-related infection? Injury 2021; 52:2879-2885. [PMID: 34412852 DOI: 10.1016/j.injury.2021.08.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/31/2021] [Accepted: 08/04/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fracture-related infection (FRI) remains one of the most challenging complications in orthopaedic trauma surgery. An early diagnosis is of paramount importance to guide treatment. The primary aim of this study was to compare the Centers for Disease Control and Prevention (CDC) criteria for the diagnosis of organ/space surgical site infection (SSI) to the recently developed diagnostic criteria of the FRI consensus definition in operatively treated fracture patients. METHODS This international multicenter retrospective cohort study evaluated 257 patients with 261 infections after operative fracture treatment. All patients included in this study were considered to have an FRI and treated accordingly ('intention to treat'). The minimum follow-up was one year. Infections were scored according to the CDC criteria for organ/space SSI and the diagnostic criteria of the FRI consensus definition. RESULTS Overall, 130 (49.8%) FRIs were captured when applying the CDC criteria for organ/space SSI, whereas 258 (98.9%) FRIs were captured when applying the FRI consensus criteria. Patients could not be classified as having an infection according to the CDC criteria mainly due to a lack of symptoms within 90 days after the surgical procedure (n = 96; 36.8%) and due to the fact that the surgery was performed at an anatomical localization not listed in the National Healthcare Safety Network (NHSN) operative procedure code mapping (n = 37; 14.2%). CONCLUSION This study confirms the importance of standardization with respect to the diagnosis of FRI. The results endorse the recently developed FRI consensus definition. When applying these diagnostic criteria, 98.9% of the infections that occured after operative fracture treatment could be captured. The CDC criteria for organ/space SSI captured less than half of the patients with an FRI requiring treatment, and seemed to have less diagnostic value in this patient population.
Collapse
|
25
|
Yu YH, Lin YT, Hsu YH, Chou YC, Ueng SWN, Liu SJ. Biodegradable Antimicrobial Agent/Analgesic/Bone Morphogenetic Protein-Loaded Nanofibrous Fixators for Bone Fracture Repair. Int J Nanomedicine 2021; 16:5357-5370. [PMID: 34408414 PMCID: PMC8364851 DOI: 10.2147/ijn.s325885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/03/2021] [Indexed: 12/28/2022] Open
Abstract
Purpose Postoperative infection and pain management are of great concern to orthopedic surgeons. Although there are several protocols available to deal with these aspects, they are fraught with complications, such as cartilage damage, cardiovascular and neurological intoxication, and systemic adverse responses. Therefore, it is necessary to develop safe and effective perioperative protocols. In the current study, antimicrobial agents/analgesics/growth factor-embedded biodegradable hybrid fixators (polycaprolactone fixator + poly[lactide-co-glycolide] sheath-core structured nanofibers) for bone fracture repair were designed. Methods The biodegradable hybrid fixators were fabricated using solution-extrusion three-dimensional printing and electrospinning. In vitro, the characteristics of the hybrid fixators were examined. Additionally, the release of the incorporated vancomycin, ceftazidime, lidocaine, and bone morphogenetic protein-2 (BMP-2) was evaluated. The in vivo efficacy including drug-eluting properties, fracture repair, and pain management of the biomolecule-loaded nanofibrous fixators was investigated in rabbit rib-fracture models. Results The nanofibrous fixators released vancomycin, ceftazidime, and lidocaine in a sustained manner under both in vitro and in vivo conditions and protected BMP-2 from burst release. The implantation of these hybrid fixators around the fractured rib significantly improved animal activities and bone union, indicating that the inclusion of analgesic in the fixator effectively reduced postsurgical pain and thereby helped in recovery. Conclusion The novel biomolecule-loaded nanofibrous hybrid fixators resulted in excellent therapeutic outcomes. These fixators may be effective in the repair of rib fractures in clinical settings and may help mitigate surgical complications, such as infection, nonunion, and intolerable postoperative pain.
Collapse
Affiliation(s)
- Yi-Hsun Yu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan, 33305, Taiwan
| | - Yu-Ting Lin
- Department of Mechanical Engineering, Chang Gung University, Tao-Yuan, 33302, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan, 33305, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan, 33305, Taiwan
| | - Steve W N Ueng
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan, 33305, Taiwan
| | - Shih-Jung Liu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan, 33305, Taiwan.,Department of Mechanical Engineering, Chang Gung University, Tao-Yuan, 33302, Taiwan
| |
Collapse
|
26
|
Mener A, Staley C, Boissonneault A, Reisman W, Schenker M, Hernandez-Irizarry R. Infection after Open Long Bone Fractures: Can we Improve on Prophylaxis? J Surg Res 2021; 268:33-39. [PMID: 34280663 DOI: 10.1016/j.jss.2021.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 03/14/2021] [Accepted: 05/26/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Current standards recommend antibiotic prophylaxis administered after open fracture injury. The purpose of this study was to assess culture results in patients with open fracture-associated infections, hypothesizing that cultures obtained do not vary by Gustilo-Anderson (GA) classification. METHODS We examined cultured bacterial species from patients with open long bone fractures that underwent irrigation and debridement at a Level 1 trauma center (2008-2016), evaluating our current and two hypothetical antibiotic protocols to assess whether they provided appropriate coverage. The antibiotic protocols included protocols 1 (cefazolin, with gentamicin added for type III fractures), 2 (vancomycin and cefepime) and 3 (ceftriaxone). RESULTS GA classification was not associated with bacterial gram stain (P = 0.161), nor was it predictive of mono- versus polymicrobial infection (P = 0.094). Of 42 culture-positive infections, 31 were type III and 11 were type I or II fractures. 27% of the infections for type I or II fractures were caused by organisms targeted by protocol 1 (OR 0.18, 95% CI 0.04-0.82; P = 0.027). There was no difference in coverage by fracture type among protocol 2 (P = 0.771) or protocol 3 (P = 0.891). For type III fractures, protocol 2 provided 94% appropriate coverage compared to 68% and 61% coverage by protocols 1 and 3, respectively. CONCLUSION For open fractures complicated by infection, isolated bacterial organisms do not correlate with GA open fracture classification, suggesting that hypothetical protocol 2 should be used for all fracture types. Protocol 2's broad coverage, across all GA fracture types, may prevent infection by organisms not covered by current antibiotic prophylaxis.
Collapse
Affiliation(s)
- Amanda Mener
- Emory University School of Medicine, Atlanta, GA
| | | | - Adam Boissonneault
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - William Reisman
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Mara Schenker
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | | |
Collapse
|
27
|
Franz D, Raschke M, Giannoudis PV, Leliveld M, Metsemakers WJ, Verhofstad MHJ, Craig JA, Shore J, Smith A, Muehlendyck C, Kerstan M, Fuchs T. Use of antibiotic coated intramedullary nails in open tibia fractures: A European medical resource use and cost-effectiveness analysis. Injury 2021; 52:1951-1958. [PMID: 34001375 DOI: 10.1016/j.injury.2021.04.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/01/2021] [Accepted: 04/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE In patients with open tibial fractures, bone and wound infections are associated with an increased hospital length of stay and higher costs. The infection risk increases with the use of implants. Innovations to reduce this risk include antibiotic-coated implants. This study models whether the use of a gentamicin-coated intramedullary tibial nail is cost-effective for trauma centers managing patients with a high risk of infection. EFFICACY Absolute infection risk and relative risk reduction, by fracture grade, for antibiotic-coated nails compared to standard nails for patients with open tibial fractures were estimated based on the results of a meta-analysis, which assessed the additional benefit of locally-administered prophylactic antibiotics in open tibia fractures treated with implants. The observed efficacy of antibiotic-coated nails in reducing infections was applied in an economic model. METHODS The model compared infection rates, inpatient days, theatre usage and costs in high risk patients, with a Gustilo-Anderson (GA) grade III open fracture, for two patient cohorts from a trauma center perspective, with a 1-year time horizon. In one cohort all GAIII patients received a gentamicin-coated nail whilst GAI and GAII patients received a standard nail. All patients in the comparator cohort received a standard nail. Four European trauma centers provided patient-level data (n=193) on inpatient days, procedures and related costs for patients with and without infections. RESULTS Using the gentamicin-coated nail in patients at high risk of infection (GAIII) was associated with 75% lower rate of infection and cost savings (€477 - €3.263) for all included centers; the higher cost of the implant was offset by savings from fewer infections, inpatient days (-26%) and re-operations (-10%). This result was confirmed by extensive sensitivity analyses. CONCLUSIONS Analyses demonstrated that infection rates and total costs for in-hospital treatment could be potentially reduced by 75% and up to 15% respectively, by using a gentamicin-coated nail in patients at high risk of infection. Fewer infections, reduced inpatient days and re-operations may be potentially associated with use of antibiotic-coated implants. Results are sensitive to the underlying infection risk, with greatest efficacy and cost-savings when the coated implant is used in high risk patients.
Collapse
Affiliation(s)
- D Franz
- Franz und Wenke, Beratung im Gesundheitswesen GbR, Technologiehof Mendelstraße 11, 48149 Münster, Germany.
| | - M Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Germany.
| | - P V Giannoudis
- Department of Trauma and Orthopaedic Surgery, University Hospital of Leeds, England.
| | - M Leliveld
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.
| | - W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium.
| | - M H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.
| | - J A Craig
- York Health Economics Consortium, University of York, York, UK, YO10 5NQ.
| | - J Shore
- York Health Economics Consortium, University of York, York, UK, YO10 5NQ.
| | - A Smith
- Health Economics Consortium, University of York, York, UK, YO10 5NQ.
| | - C Muehlendyck
- J&J, Hummelsbutteler Steindamm 71, 22851 Norderstedt, Germany.
| | - M Kerstan
- J&J, Synthes GmbH, Luzernstrasse 21, 4528 Zuchwil, Switzerland.
| | - T Fuchs
- Vivantes Klinikum im Friedrichshain, Zentrum für Muskuloskelettale Medizin, Klinik für Orthopädie, Unfall-, Hand- und Wiederherstellungschirurgie Standort Landsberger Allee 49, 10249 Berlin, Germany.
| |
Collapse
|
28
|
Current concepts in the prevention, diagnosis and treatment of fracture-related infection (FRI). EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:957-966. [PMID: 33778904 DOI: 10.1007/s00590-021-02956-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/21/2021] [Indexed: 12/24/2022]
Abstract
Fracture-related infection (FRI) is one of the most challenging complications following operative management of fractures. It can have profound implications for the patient, can be associated with considerable morbidity and often lead to impaired outcomes. There are significant healthcare-related costs. In recent years, there has been significant progress towards developing preventative strategies. Furthermore, diagnostic algorithms and management protocols have recently been reported. Lack of a strong evidence base has previously hindered efforts to implement these and develop established standards of care. There are multiple aspects of care that need to be considered and a multi-disciplinary approach is recommended. In this narrative review, we present the most up-to-date recommendations in the prevention, diagnosis and management of FRI.
Collapse
|
29
|
Militz M, Ellenrieder M. [Management of suspected early infection after osteosynthesis]. Chirurg 2021; 92:963-972. [PMID: 33770190 DOI: 10.1007/s00104-021-01377-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/29/2022]
Abstract
The infection rate after fracture osteosynthesis depends on many factors. The postoperative infection rate after osteosynthesis (inpatient treatment) was between 1.15% and 2.04% for the years 2017-2019. The total number of postoperative wound infections was estimated at around 225,000 annually in 2018. Essential factors for reducing the infection rate after osteosynthesis are the favorable choice of the timing of the operation and the surgical procedure as well as the treatment of relevant secondary diseases. If a postoperative wound infection is suspected critical assessment of the wounds in the postoperative course is essential in order to be able to identify and treat this complication at an early stage. After osteosynthesis, early diagnosis of a peri-implant infection and differentiated surgical and antibiotic treatment are the prerequisites for the best possible treatment success.
Collapse
Affiliation(s)
- Matthias Militz
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Prof.-Küntscher-Straße 8, 82418, Murnau, Deutschland.
| | - Martin Ellenrieder
- Orthopädische Klinik und Poliklinik, Doberaner Straße 142, 18057, Rostock, Deutschland
| |
Collapse
|
30
|
Prada C, Marcano-Fernández FA, Schemitsch EH, Bzovsky S, Jeray K, Petrisor B, Bhandari M, Sprague S. Timing and Management of Surgical Site Infections in Patients With Open Fracture Wounds: A Fluid Lavage of Open Wounds Cohort Secondary Analysis. J Orthop Trauma 2021; 35:128-135. [PMID: 33105456 DOI: 10.1097/bot.0000000000001912] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Many studies report on the incidence or prevalence of fracture-related surgical site infections (SSIs) after open fractures; however, few studies report on their timing and management outcomes. To address this gap, we used data from the Fluid Lavage of Open Wounds trial to determine timing of diagnosis, management, and resolution of SSIs. METHODS All participants included in this analysis had an SSI after an open fracture. Participants were assigned to a group based on the type of SSI as follows: (1) those who developed a superficial SSI and (2) those who had either a deep or organ/space SSI. Descriptive statistics characterized the type, timing, and management of each SSI. RESULTS Of the 2445 participants in the Fluid Lavage of Open Wounds trial, 325 (13.3%) had an SSI. Superficial SSIs were diagnosed significantly earlier [26.5 days, interquartile range (IQR) 12-48] than deep or organ/space SSIs (53 days, IQR 15-119). Of the 325 patients with SSIs, 174 required operative management and 151 were treated nonoperatively. For SSIs managed operatively, median time for infection resolution was 73 days (IQR 28-165), and on average, 1.73 surgeries (95% confidence interval 1.58-1.88) were needed during the 12 months follow-up. There were 24 cases whose SSIs were not resolved at the time of the final follow-up visit (12 months). CONCLUSIONS Based on this study's findings and in contradistinction to the Centers for Disease Control and Prevention guidelines, after an open fracture, superficial SSIs were diagnosed at one month and deep/organ/space SSIs at 2 months. This information can allow for earlier infection detection. In addition, the knowledge that approximately 50% of the SSIs in our study required a reoperation and 3 months at a minimum to resolve will assist orthopaedic surgeons when counseling their patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Carlos Prada
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Francesc A Marcano-Fernández
- Orthopaedic Department, Parc Taulí Hospital Universitari, Institut D'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Emil H Schemitsch
- Department of Surgery, University of Western Ontario, London, ON, Canada
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Kyle Jeray
- Department of Orthopaedic Surgery, Greenville Health System, Greenville, SC; and
| | - Brad Petrisor
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
31
|
What is the optimal timing for bone grafting during staged management of infected non-unions of the tibia? A systematic review and best evidence synthesis. Injury 2020; 51:2793-2803. [PMID: 33131793 DOI: 10.1016/j.injury.2020.10.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/07/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To summarize the best available evidence with regards to timing of staged bone grafting for infected tibial non-union, and to extract evidence-based criteria indicating when bone grafting can be safely performed. METHODS Medline, Embase, Scopus, and Google Scholar were searched, and publications of evidence Level I-IV from 2000 to 2020 were included. Risk of bias was assessed with the Cochrane Collaboration's Risk of Bias Tool and ROBINS-I tool. Study quality was assessed with the GRADE system, Coleman methodology score, and Methodological Index for Non-Randomized Studies (MINORS). Heterogeneity was assessed with the I2 statistic. A forest plot was used to pool the timing of bone grafting for all included studies. For data synthesis and analysis, a best evidence synthesis was used. RESULTS A total of 15 studies were included (353 cases). Risk of bias was high in 8 studies and the quality for 14 studies was assessed as very low, with a mean Coleman score of 33.5 and a mean MINORS score of 7.9. The mean time from the index surgery to bone grafting was 7.03 weeks ranging from 2 to 15 weeks (lower limit 6 weeks, upper limit 8.07 weeks). Best evidence analysis demonstrated that 8 of the 15 studies (53%) with 237 cases (67%) performed staged bone grafting inside this window. Union was achieved in 92%. CONCLUSION The results of this best evidence systematic review suggest that, for most infected tibial non-unions, secondary bone grafting can be successfully performed between 6-8 weeks with expected union rates over 90%.
Collapse
|
32
|
How Successful Is Antibiotic Treatment for Superficial Surgical Site Infections After Open Fracture? A Fluid Lavage of Open Wounds (FLOW) Cohort Secondary Analysis. Clin Orthop Relat Res 2020; 478:2846-2855. [PMID: 32412929 PMCID: PMC7899390 DOI: 10.1097/corr.0000000000001293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although many studies report the incidence and prevalence of surgical site infections (SSIs) after open fractures, there is limited information on the treatment and subsequent outcomes of superficial SSIs in patients with open fractures. Additionally, clinical studies describing the factors that are associated with persistent infection after nonoperative treatment with antibiotics for patients with superficial SSIs are lacking. QUESTIONS/PURPOSES Therefore, we asked: (1) What proportion of patients with superficial SSIs after open fracture treatment developed persistent infection after nonoperative treatment (that is, treatment with antibiotics alone)? (2) What risk factors are associated with SSIs that do not resolve with nonoperative (antibiotic) treatment? As a secondary objective, we planned to analyze the microbiological information about participants wound cultures, when these were available, and the proportion of positive cultures for patients whose SSIs were not resolved by antibiotics alone. METHODS This is a secondary analysis of the Fluid Lavage of Open Wounds (FLOW) trial dataset. The FLOW trial included 2445 patients with operatively managed open fractures. FLOW participants who had a nonoperatively managed superficial SSI diagnosed in the 12 months post-fracture were included in this analysis. Superficial SSIs were diagnosed in 168 participants within 12 months of their fracture. Of these, 83% (139) had their superficial SSI treated with antibiotics alone. Participants were grouped into two categories: (1) 97 participants whose treatment with antibiotics alone resolved the superficial SSI and (2) 42 participants whose treatment with antibiotics alone did not resolve the SSI (defined as undergoing surgical management or the SSI being unresolved at latest follow-up [12-months post-fracture for the FLOW trial]). Of the participants whose treatment with antibiotics alone resolved the SSI, 92% (89 of 97) had complete follow-up, 6% (6 of 97) were lost to follow-up before 12 months, 1% (1 of 97) withdrew consent from the study before 12 months, and 1% (1 of 97) experienced mortality before 12 months. Of the participants whose treatment with antibiotics alone did not resolve the SSI, 90% (38 of 42) had complete follow-up, 7% (3 of 42) were lost to follow-up before 12 months, and 2% (1 of 42) withdrew consent from the study before 12 months. A logistic binary regression analysis was conducted to identify factors associated with persistent infection despite superficial SSI antibiotic treatment. Based on biologic rationale and previous evidence, we identified a priori 13 potential factors (corresponding to 14 levels) to be included in the regression model. RESULTS The antibiotic treatment resolved the superficial SSI in 70% (97 of 139) of patients and did not resolve the SSI in 30% (42 of 139). After controlling for potential confounding variables, such as age, fracture severity, and time from injury to initial surgical irrigation and débridement, superficial SSIs diagnosed later in follow-up were associated with antibiotics not resolving the SSI (odds ratio 1.05 [95% CI 1.004 to 1.009] for every week of follow-up; p = 0.03). Sex, fracture pattern, and wound size were not associated with antibiotics not resolving the SSI. CONCLUSIONS Our secondary analysis of prospectively collected FLOW data suggests that antibiotics alone can be an appropriate treatment option when treating superficial SSIs after an open fracture wound, especially when promptly diagnosed. Further research with longer follow-up time is needed to better identify the natural history of superficial SSIs and possibly some dormant or subclinical infections to help clinicians in the treatment decision-making process. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
|
33
|
Li A, Thomas RZ, van der Sluis L, Tjakkes G, Slot DE. Definitions used for a healthy periodontium-A systematic review. Int J Dent Hyg 2020; 18:327-343. [PMID: 32330350 PMCID: PMC7687205 DOI: 10.1111/idh.12438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/07/2020] [Accepted: 04/20/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To investigate the explicitness and variability of the definition of periodontal health in the current scientific literature. MATERIAL AND METHODS The authors conducted a systematic literature review using PubMed and CENTRAL (2013-01/2019-05) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the guidelines of the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) statement. RESULTS A total of 51 papers met the predefined inclusion criteria. Of these, 13 papers did not report any explicit definitions of periodontal health. Out of the 38 remaining articles, half of them used a reference to support their definition and half of them not. The studies published in periodontics-related journals or those that scored a low risk of bias for the methodical quality presented more explicit and valid definitions. Probing pocket depth was the most frequently used individual parameter for defining periodontal health. However, there were substantial variations in the methods of measurement and cut-off values. CONCLUSIONS Given the diversity of periodontal health definitions, a cross-study comparison is difficult. The results of this review may be useful in making others aware of the significance of standardizing the definition of a healthy periodontium.
Collapse
Affiliation(s)
- An Li
- Center for Dentistry and Oral HygieneUniversity Medical Center Groningen (UMCG)University of GroningenGroningenThe Netherlands
| | - Renske Z. Thomas
- Center for Dentistry and Oral HygieneUniversity Medical Center Groningen (UMCG)University of GroningenGroningenThe Netherlands
- Department of DentistryRadboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Luc van der Sluis
- Center for Dentistry and Oral HygieneUniversity Medical Center Groningen (UMCG)University of GroningenGroningenThe Netherlands
| | - Geerten‐Has Tjakkes
- Center for Dentistry and Oral HygieneUniversity Medical Center Groningen (UMCG)University of GroningenGroningenThe Netherlands
| | - Dagmar Else Slot
- Department of PeriodontologyAcademic Centre for Dentistry Amsterdam (ACTA)University of Amsterdam and Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| |
Collapse
|
34
|
Cerioli M, Batailler C, Conrad A, Roux S, Perpoint T, Becker A, Triffault-Fillit C, Lustig S, Fessy MH, Laurent F, Valour F, Chidiac C, Ferry T. Pseudomonas aeruginosa Implant-Associated Bone and Joint Infections: Experience in a Regional Reference Center in France. Front Med (Lausanne) 2020; 7:513242. [PMID: 33195289 PMCID: PMC7649271 DOI: 10.3389/fmed.2020.513242] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 09/22/2020] [Indexed: 11/18/2022] Open
Abstract
Background:P. aeruginosa implant-associated bone and joint infections (BJI) is considered to be one of the most difficult to treat BJI. The data focusing specifically on this pathogen are sparse, and it seems difficult to extrapolate the results obtained with Enterobacteriaceae. Methods: We performed a retrospective observation study of all P. aeruginosa implant-associated BJI diagnosed at our institution from 2011 to 2018. We defined failure as any type of relapse, including persistence of the same P. aeruginosa, superinfection by another organism(s) or any other cause of relapse such as the need for a subsequent surgery. Nonparametric statistical methods were used to compare the study groups and Kaplan-Meier curves and multivariate Cox analysis and were used to detect determinants associated with treatment failure. Results: A total of 90 patients (62% men, median age 60 years IQR 47–72) including 30 (33%) prosthetic-joint infections and 60 (66%) other implant-associated BJIs were studied. Most of them were acute (62%). During the prolonged follow-up, (median 20 months; IQR 9–37), 23 patients (26%) experienced treatment failure. Optimal surgical treatment (DAIR for acute forms, explantation, 1-stage or 2-stage exchange for others) was significantly associated with a higher success rate in the univariate analysis (p = 0.003). Sixty-four (71%) patients received effective initial treatment against P. aeruginosa administered and 81 of them (90%) did for at least 3 weeks: both these parameters correlated with a higher success rate. In the multivariate Cox-analysis optimal surgical treatment, IV effective treatment of at least 3 weeks and treatment with ciprofloxacin for at least 3 months proved to be independently associated to a better outcome in patients with P. aeruginosa implant-associated BJI. Conclusion:P. aeruginosa implant-associated BJI is one of the most difficult-to-treat BJI, with a strong impact on the prognosis of the surgical strategy. An effective initial IV antibiotic treatment for at least 3 weeks seems to be required, followed by oral ciprofloxacin for a total duration of 3 months.
Collapse
Affiliation(s)
| | - Cécile Batailler
- Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Anne Conrad
- Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France
| | - Sandrine Roux
- Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Thomas Perpoint
- Hospices Civils de Lyon, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Agathe Becker
- Hospices Civils de Lyon, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Claire Triffault-Fillit
- Hospices Civils de Lyon, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Sebastien Lustig
- Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Michel-Henri Fessy
- Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Frederic Laurent
- Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France
| | - Florent Valour
- Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France
| | - Christian Chidiac
- Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France
| | - Tristan Ferry
- Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France
| |
Collapse
|
35
|
McNally M, Govaert G, Dudareva M, Morgenstern M, Metsemakers WJ. Definition and diagnosis of fracture-related infection. EFORT Open Rev 2020; 5:614-619. [PMID: 33204503 PMCID: PMC7608516 DOI: 10.1302/2058-5241.5.190072] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Fracture-related infection (FRI) is common and often diagnosed late.Accurate diagnosis is the beginning of effective treatment.Diagnosis can be difficult, particularly when there are no outward signs of infection.The new FRI definition, together with clear protocols for nuclear imaging, microbiological culture and histological analysis, should allow much better study design and a clearer understanding of infected fractures.In recent years, there has been a new focus on defining FRI and avoiding non-specific, poorly targeted treatment. Previous studies on FRI have often failed to define infection precisely and so are of limited value. This review highlights the essential principles of making the diagnosis and how clinical signs, serum tests, imaging, microbiology, molecular biology and histology all contribute to the diagnostic pathway. Cite this article: EFORT Open Rev 2020;5:614-619. DOI: 10.1302/2058-5241.5.190072.
Collapse
Affiliation(s)
- Martin McNally
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Geertje Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria Dudareva
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | | |
Collapse
|
36
|
Galvain T, Chitnis A, Paparouni K, Tong C, Holy CE, Giannoudis PV. The economic burden of infections following intramedullary nailing for a tibial shaft fracture in England. BMJ Open 2020; 10:e035404. [PMID: 32847903 PMCID: PMC7451536 DOI: 10.1136/bmjopen-2019-035404] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Determine the impact of infections on direct costs and healthcare resource use in England for patients undergoing intramedullary nailing (IMN) for tibial shaft fractures. DESIGN Non-concurrent cohort based on retrospectively collected data with 2-year follow-up. SETTING England. PARTICIPANTS The study population included adult patients (≥18 years) in England with a diagnosis of tibial shaft fracture (International Classification of Diseases-10, S822) in the inpatient setting between May 2003 and June 2017 followed by a procedure for IMN for tibial shaft fracture within 30 days. Patient data were derived from the Clinical Practice Research Datalink linked to National Health Service Hospital Episode Statistics datasets. PRIMARY INDEPENDENT VARIABLE Infection. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was total inpatient costs from index stay admission through 1 year of follow-up. Secondary outcome included cumulative total healthcare costs, and resource utilisation at 30 days, 90 days, 1 year and 2 years. RESULTS Overall, 805 patients met the inclusion criteria. At index inpatient stay, 3.7% had a post-IMN infection, rising to 11.7% at 1 year. One-year inpatient costs were 80% higher for patients with infection (p<0.001). Total costs were estimated to be £14 756 (95% CI £13 123 to £16 593) for patients with infection versus £8279 (95% CI £7946 to £8626). Length of stay (LOS), readmission and reoperation were the key drivers of healthcare costs (all p<0.001). After adjustment, LOS was higher by 109% (95% CI 62% to 169%), from 10.5 days to 21.9 days, for patients with infection. The odds of being readmitted or requiring reoperation were higher by 5.18 times (95% CI 3.01 to 9.13) and 2.47 times (95% CI 1.48 to 4.09), respectively, for patients with infection versus those without infection. CONCLUSIONS Post-IMN infection significantly increases inpatient costs, LOS, readmissions and reoperations associated with tibial fracture fixation. Healthcare burden could be reduced through novel surgical site infection prevention strategies.
Collapse
Affiliation(s)
- Thibaut Galvain
- Department of Health Economics and Market Access, Johnson and Johnson Medical Devices, Issy-les-Moulineaux, France
| | - Abhishek Chitnis
- Department of Real World Analytics and Research, Johnson and Johnson Medical Devices, New Brunswick, New Jersey, USA
| | - Konstantina Paparouni
- Department of Health Economics and Market Access, DePuy Synthes, Zuchwil, Switzerland
| | - Cindy Tong
- Department of Health Economics and Market Access, Johnson and Johnson Medical Devices, Somerville, New Jersey, USA
| | - Chantal E Holy
- Department of Real World Analytics and Research, Johnson and Johnson Medical Devices, New Brunswick, New Jersey, USA
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK
- School of Medicine, University of Leeds, Leeds, West Yorkshire, UK
| |
Collapse
|
37
|
How to Diagnose Surgical Site Infection After Fracture Surgery: We Have a Problem! Tech Orthop 2020. [DOI: 10.1097/bto.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
38
|
Obremskey WT, Metsemakers WJ, Schlatterer DR, Tetsworth K, Egol K, Kates S, McNally M. Musculoskeletal Infection in Orthopaedic Trauma: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection. J Bone Joint Surg Am 2020; 102:e44. [PMID: 32118653 DOI: 10.2106/jbjs.19.01070] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fracture-related infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.
Collapse
Affiliation(s)
- William T Obremskey
- Department of Orthopaedic Trauma, Vanderbilt Medical Center, Nashville, Tennessee
| | | | | | - Kevin Tetsworth
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia.,Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Kenneth Egol
- Department of Orthopedic Surgery, NYU School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Stephen Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Martin McNally
- Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | | | | |
Collapse
|
39
|
Traumatic Orthopaedic Injuries in the Prison Population. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:JAAOSGlobal-D-20-00031. [PMID: 32377616 PMCID: PMC7188272 DOI: 10.5435/jaaosglobal-d-20-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/05/2020] [Indexed: 11/18/2022]
Abstract
The United States has the highest population of inmates in the world (per capita and total). Musculoskeletal disorders are included within the 10 most frequent medical reports of prisoners; however, the literature about them is limited. The purpose of this study is to describe the epidemiology and complications of traumatic musculoskeletal injuries. To our knowledge, this is the first report of musculoskeletal trauma and complications in the prison population. Methods A list of all traumatic orthopaedic injuries and complications, except for spine, was sent to the billing contractor of the Pennsylvania state prison system based on the Current Procedure Terminology, and it was queried over a 3-year period. Results Five hundred seventy-six patients met the criteria. The hand and wrist was the most commonly injured region (65%), followed by foot and ankle (20%). Metacarpal fracture represented 22% of all injuries. A low complication rate was noted among all surgical procedures. Infection was seen in 1.15% of hand surgeries and in 2% of ankle surgeries. In addition, a low incidence of nonunion was recorded (1.5%). Nonsurgical management was the chosen method of treatment in 64% of all injuries. Conclusion In this prison population with musculoskeletal injuries, upper extremity injuries and nonsurgical treatment are more prevalent and low energy injuries are more common. Contrary to popular belief, there is a trend toward low infection and complication rates after orthopaedic treatment. Further studies are necessary to best identify the patterns of injuries and the best way to treat inmates with orthopaedic injuries.
Collapse
|
40
|
Abstract
A precise definition of infection after fracture fixation is essential for the evaluation of published research data and for the future establishment of uniform treatment concepts. Recently, a multidisciplinary expert panel has developed a consensus definition that includes 4 confirmatory criteria for infection following fracture fixation. These criteria are: Fistula, sinus, or wound breakdown; purulent drainage or deep purulence at surgery; positive cultures from at least 2 separate deep tissue/implant specimens taken during an operative intervention; and microorganisms in deep tissue specimens confirmed by histopathological staining. The consensus panel also identified 6 categories of suggestive criteria which are features associated with infection that requires further investigation.
Collapse
|
41
|
Wang X, Wang S, Fu J, Sun D, Shen J, Xie Z. Risk factors associated with recurrence of extremity osteomyelitis treated with the induced membrane technique. Injury 2020; 51:307-311. [PMID: 31771787 DOI: 10.1016/j.injury.2019.11.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/10/2019] [Accepted: 11/20/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Our aim was to observe the efficacy of the induced membrane technique in the treatment of extremity osteomyelitis and to analyse the causes of infection recurrence and its risk factors. METHODS We retrospectively analysed 424 cases of extremity osteomyelitis treated with the induced membrane technique in our department between May 2013 and June 2017. Infection recurrence time, recurrence sites and other relevant information were collected, summarized, and analysed. RESULTS A total of 424 patients were considered as "cured" of osteomyelitis after the first stage and the induced membrane technique was performed to rebuild the bone defects. After a mean follow-up of 31.6 (16-63) months, 52 patients had recurrence of infection, including 42 tibias and 10 femurs. The recurrence rate was 12.26%. Symptoms were relieved in 16 patients after intravenous antibiotic treatment. In the remaining 36 cases (8.49%), the infection was uncontrolled by intravenous antibiotics and surgical debridement was performed. The recurrence rate of infection of the tibia (16.22%) was higher than that of the femur (8.70%). The recurrence rate of post-traumatic osteomyelitis (14.66%) was significantly higher than that of hematogenous osteomyelitis (2.41%). Patients in whom Pseudomonas aeruginosa was isolated at the first stage had a recurrence rate of 28% (7/25), which was higher than that with the other isolated bacteria. Logistic regression analysis showed that repeated operations (≥3), post-traumatic osteomyelitis, and internal fixation at the first stage were risk factors for recurrence of infection, with odds ratios (ORs) of 2.30, 5.53 and 5.28 respectively. CONCLUSIONS The induced membrane technique is an effective method in the treatment of extremity osteomyelitis, although infection recurs in some cases. Repeated operations, post-traumatic osteomyelitis, and internal fixation at the first stage were risk factors for recurrence of infection. P. aeruginosa isolated at the first stage, tibia osteomyelitis, the presence of sinus, or flaps may also be associated with recurrence of infection.
Collapse
Affiliation(s)
- Xiaohua Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China
| | - Shulin Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China
| | - Jingshu Fu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China
| | - Dong Sun
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China
| | - Jie Shen
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China
| | - Zhao Xie
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China.
| |
Collapse
|
42
|
Govaert GAM, Kuehl R, Atkins BL, Trampuz A, Morgenstern M, Obremskey WT, Verhofstad MHJ, McNally MA, Metsemakers WJ. Diagnosing Fracture-Related Infection: Current Concepts and Recommendations. J Orthop Trauma 2020; 34:8-17. [PMID: 31855973 PMCID: PMC6903359 DOI: 10.1097/bot.0000000000001614] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 02/02/2023]
Abstract
Fracture-related infection (FRI) is a severe complication after bone injury and can pose a serious diagnostic challenge. Overall, there is a limited amount of scientific evidence regarding diagnostic criteria for FRI. For this reason, the AO Foundation and the European Bone and Joint Infection Society proposed a consensus definition for FRI to standardize the diagnostic criteria and improve the quality of patient care and applicability of future studies regarding this condition. The aim of this article was to summarize the available evidence and provide recommendations for the diagnosis of FRI. For this purpose, the FRI consensus definition will be discussed together with a proposal for an update based on the available evidence relating to the diagnostic value of clinical parameters, serum inflammatory markers, imaging modalities, tissue and sonication fluid sampling, molecular biology techniques, and histopathological examination. Second, recommendations on microbiology specimen sampling and laboratory operating procedures relevant to FRI will be provided. LEVEL OF EVIDENCE:: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Geertje A. M. Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Richard Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - Bridget L. Atkins
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Michael H. J. Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; and
| | - Martin A. McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | | |
Collapse
|
43
|
Jensen LK, Henriksen NL, Blirup SA, Jensen HE. Guideline for Preclinical Studies of Bone Infections in Large Animals Based on a Systematic Review of 316 Non-Rodent Models. J Bone Joint Surg Am 2019; 101:1894-1903. [PMID: 31567666 DOI: 10.2106/jbjs.18.01369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In recent years, animal models of bone infections have been used with increased frequency in order to evaluate novel diagnostic and anti-infective technologies, like antibacterial coating of bone implants or local antibiotic carrier products. Therefore, it is highly relevant to evaluate the scientific quality of existing bone infection models. METHODS We conducted a systematic review of 316 studies of large non-rodent animal models of bone infection (254 rabbit, 16 pig, 23 dog, 11 goat, and 12 sheep) and extracted data on study design, methodological quality, and postmortem evaluation of infection with respect to reporting and quantification of pathology and microbiology. RESULTS The review demonstrated a substantial lack of study-design information, which hampers reproducibility and continuation of the established work. Furthermore, the methodological study quality was found to be low, as the definition of infection, randomization, power analysis, and blinding were only seldomly reported. The use of histology increased in recent years, but a semi-quantitative scoring of the lesions was often missing, i.e. no objective quantification of outcome. Most of the studies focused on whether the inoculated bacteria were present within the bone tissue post mortem or not. However, very often the bacterial burden was not quantified. In many of the models, different antimicrobial interventions were examined and, although antimicrobial effects were commonly described, a lack of complete sterile outcome was observed in many models. On the basis of the systematic review, we established a study template providing a guideline for the standard reporting of animal models of bone infections, including details related to the animal, pathogen, infected animal, and postmortem analysis that are of crucial importance for validation of results and reproducibility. CONCLUSIONS As the aim of many bone infection models is to examine the effect of an intervention, the guideline emphasizes the importance of objective quantification of outcome, e.g., blinded quantitative scoring of histological findings and quantification of bacterial burden within tissue and on inserted implants. Less than 5% of the analyzed studies adhered completely to the ideal form presented in the study template. CLINICAL RELEVANCE Anti-infective interventions must be tested in preclinical animal models before implementation in human patients, and optimal design and validation is essential for a high translational value.
Collapse
Affiliation(s)
- L K Jensen
- Section for Pathobiological Sciences, Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark
| | - N L Henriksen
- Section for Pathobiological Sciences, Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark
| | - S A Blirup
- Section for Pathobiological Sciences, Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark
| | - H E Jensen
- Section for Pathobiological Sciences, Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
44
|
Jiang N, Wang BW, Chai YM, Wu XB, Tang PF, Zhang YZ, Yu B. Chinese expert consensus on diagnosis and treatment of infection after fracture fixation. Injury 2019; 50:1952-1958. [PMID: 31445830 DOI: 10.1016/j.injury.2019.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Currently, accurate diagnosis and successful treatment of infection after fracture fixation (IAFF) still impose great challenges. According to the onset of infection symptoms after implantation, IAFF is classified as early infection (<2 weeks), delayed infection (2∼10 weeks) and late infection (>10 weeks). Confirmation of IAFF should be supported by histopathological tests of intraoperative specimens which confirm infection, cultures from at least two suspected infection sites which reveal the same pathogen, a definite sinus or fistula which connects directly the bone or the implant, and purulent drainage from the wound or presence of pus during surgery. Diagnosis of IAFF is built on comprehensive assessment of medical history, clinical signs and symptoms of the patient, and imaging and laboratory tests. The gold standard of diagnosis is histopathological tests. Treatment of IAFF consists of radical debridement, adequate irrigation, implant handling, systematic and local antibiotics, reconstruction of osseous and/or soft tissue defects, and functional rehabilitation of an affected limb. Early accurate diagnosis and appropriate treatment of IAFF play a key role in increasing the cure rate, reducing infection recurrence and disability risk, restoring limb function and improving quality of life of the patient.
Collapse
Affiliation(s)
- Nan Jiang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Bo-Wei Wang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Yi-Min Chai
- Department of Orthopaedics, The Sixth People's Hospital of Shanghai Jiao Tong University, Shanghai, PR China
| | - Xin-Bao Wu
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Beijing, PR China.
| | - Pei-Fu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, PR China.
| | - Ying-Ze Zhang
- Department of Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China.
| | - Bin Yu
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China.
| |
Collapse
|
45
|
|
46
|
Büren C, Hambüchen M, Windolf J, Lögters T, Windolf CD. Histological score for degrees of severity in an implant-associated infection model in mice. Arch Orthop Trauma Surg 2019; 139:1235-1244. [PMID: 31020411 DOI: 10.1007/s00402-019-03188-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Several scores were introduced to diagnose and to classify osteomyelitis in practice. Mouse models are often used to study the pathophysiology of bone infection and to test therapeutic strategies. Aim of the present study was to design a score to diagnose and quantify implant-associated infection in a murine experimental model. MATERIALS AND METHODS Four independent parameters were developed: existence of callus, consolidation of the fracture, structural changes of the medullary cavity and number of bacteria. The score was assessed in a standardized implant-associated mouse model with 35 BALB/c-mice. The left femur was osteotomized, fixed by a titanium locking plate and infection was induced by inoculation of Staphylococcus aureus into the fracture gap. For the sham group, the procedure was performed without inoculation of bacteria. The score was assessed on days 7, 14 and 28. Each item of the score showed lower values for the infection group compared to the controls after 4 weeks. RESULTS Regardless of the assessed time point, the overall total score was significantly higher in the control group compared to the infection group (p < 0.0001). Analysis revealed a sensitivity of 0.85, specificity of 1.0, negative predictive value of 0.67 and positive predictive value of 1.0. CONCLUSION The proposed score assessing severity of fracture-related infection in an implant-associated murine model was easy to access, feasible to diagnose and estimate bone healing and infection in a murine bone infection with a high sensitivity. Therefore, this score might be a useful tool to quantify infection-related changes after fracture in further future preclinical studies.
Collapse
Affiliation(s)
- Carina Büren
- Department for Trauma- and Hand Surgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Michael Hambüchen
- Department for Plastic and Aesthetic Surgery, Florence-Nightingale Hospital, Kreuzbergstraße 79, 40489, Düsseldorf, Germany
| | - Joachim Windolf
- Department for Trauma- and Hand Surgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Tim Lögters
- Department of Trauma-, Hand- and Orthopedic Surgery, St. Antonius Hospital Cologne, Schillerstraße 23, 50968, Cologne, Germany
| | - Ceylan Daniela Windolf
- Department for Trauma- and Hand Surgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| |
Collapse
|
47
|
Pathogenesis and management of fracture-related infection. Clin Microbiol Infect 2019; 26:572-578. [PMID: 31446152 DOI: 10.1016/j.cmi.2019.08.006] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/09/2019] [Accepted: 08/10/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Both fracture-related infections (FRIs) and periprosthetic joint infections (PJIs) include orthopaedic implant-associated infections. However, key aspects of management differ due to the bone and soft tissue damage in FRIs and the option of removing the implant after fracture healing. In contrast to PJIs, research and guidelines for diagnosis and treatment in FRIs are scarce. OBJECTIVES This narrative review aims to update clinical microbiologists, infectious disease specialists and surgeons on the management of FRIs. SOURCES A computerized search of PubMed was performed to identify relevant studies. Search terms included 'Fracture' and 'Infection'. The reference lists of all retrieved articles were checked for additional relevant references. In addition, when scientific evidence was lacking, recommendations are based on expert opinion. CONTENT Pathogenesis, prevention, diagnosis and treatment of FRIs are presented. Whenever available, specific data of patients with FRI are discussed. IMPLICATIONS Management of patients with FRI should take into account FRI-specific features. Treatment pathways should implement a multidisciplinary approach to achieve a good outcome. Recently, international consensus guidelines were developed to improve the quality of care for patients suffering from this severe complication, which are highlighted in this review.
Collapse
|
48
|
Fehring TK, Fehring KA, Hewlett A, Higuera CA, Otero JE, Tande A. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2019; 101:1237-1244. [PMID: 31318802 DOI: 10.2106/jbjs.19.00403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | | | | | - Jesse E Otero
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina
| | | |
Collapse
|
49
|
Jorge-Mora A, Amhaz-Escanlar S, Fernandez-Pose S, García-Iglesias A, Mandia-Mancebo F, Franco-Trepat E, Guillán-Fresco M, Pino-Minguez J. Commercially available antibiotic-laden PMMA-covered locking nails for the treatment of fracture-related infections - A retrospective case analysis of 10 cases. J Bone Jt Infect 2019; 4:155-162. [PMID: 31555500 PMCID: PMC6757014 DOI: 10.7150/jbji.34072] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/21/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction: Fracture-related infections (FRIs) are a devastating complication. FRIs are challenging and should be addressed with a multidisciplinary approach. An FRI should be addressed surgically by non-viable bone debridement, local antibiotic deposition, minimization of dead space and fracture stabilization. Antibiotic-laden PMMA-covered nails are a viable option to face these complications. To demonstrate the safety and utility of commercially available antibiotic-laden PMMA-covered nails, we performed a review of the cases operated in our institution and a cost analysis to compare the cost of a commercial nail to other available alternatives. Material and methods: We designed a retrospective study of consecutive cases to demonstrate the safety and efficacy of antibiotic-laden PMMA-covered commercial nails and designed a cost analysis of commercial coated nails compared to other custom-made alternatives. Results: We treated seven tibias and three femurs. Nine patients fully fit the criteria for FRI. There was one case of reintervention because of persistent drainage. All fractures healed, and in the first year post-intervention, there were no signs or symptoms of infection. There were no complications related to the commercially available nail that was used. There is a small increase in the direct quantifiable cost in commercially available nails, but non-quantifiable cost should be assessed individually. Conclusions: Commercially available antibiotic-laden PMMA-covered nails are a safe and useful treatment option for complicated cases of lower limb long bone reconstruction. The low complication rate and the straightforward technique compensate for the direct cost increase in most situations.
Collapse
Affiliation(s)
- Alberto Jorge-Mora
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain.,Faculty of Medicine, University of Santiago de Compostela, Spain.,Musculoskeletal Pathology Group, Laboratory 18, Institute IDIS, Servicio Galego de Saúde, Santiago de Compostela, Spain
| | - Samer Amhaz-Escanlar
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain.,Faculty of Medicine, University of Santiago de Compostela, Spain
| | - Sabela Fernandez-Pose
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - Adrián García-Iglesias
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - Fermín Mandia-Mancebo
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain.,Faculty of Medicine, University of Santiago de Compostela, Spain
| | - Eloi Franco-Trepat
- Musculoskeletal Pathology Group, Laboratory 18, Institute IDIS, Servicio Galego de Saúde, Santiago de Compostela, Spain
| | - María Guillán-Fresco
- Musculoskeletal Pathology Group, Laboratory 18, Institute IDIS, Servicio Galego de Saúde, Santiago de Compostela, Spain
| | - Jesús Pino-Minguez
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain.,Faculty of Medicine, University of Santiago de Compostela, Spain
| |
Collapse
|
50
|
Guerado E, Cano JR, Fernandez-Sanchez F. Pin tract infection prophylaxis and treatment. Injury 2019; 50 Suppl 1:S45-S49. [PMID: 31003703 DOI: 10.1016/j.injury.2019.03.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023]
Abstract
Pin tract infection in external fixation (ExFix) is a frequent finding which can eventually lead to loosening, osteomyelitis and loss of fixation. Its diagnosis is based on high empiricism and low validity, although it is possible to distinguish between minor and major infection. The first is limited to soft tissues, whereas the latter includes bone involvement. The rate of infection after conversion of external fixation to intramedullary nailing (IMN) is not well known. Unfortunately, papers referring to infection after the conversion of ExFix to intramedullary nailing (IMN) are of evidence level IV or V. It is suggested that conversion of ExFix to IMN should be carried out in a 2 step regimen. The time interval of 2 step regimen is uncertain although some authors have recommended to occur within 9 days. There is no consensus as to which prophylaxis protocol should be applied prior to conversion. In order to throw more light into this important issue, registries capturing important related parameters to the development of infection should be established.
Collapse
Affiliation(s)
- Enrique Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Costa del Sol, University of Malaga, Marbella (Malaga), Spain.
| | - Juan Ramon Cano
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Costa del Sol, University of Malaga, Marbella (Malaga), Spain
| | | |
Collapse
|