Diagnosis Of Fracture-related Infection Research Articles

Predictive factors for fracture-related infection in open tibial fractures in a Sub-Saharan African setting

IntroductionThe management of open tibial fractures (OTF) is challenging in low and middle-income countries (LMICs) where appropriate human resources and infrastructure (including equipment, implants and surgical supplies) are not readily available and medical care is not readily accessible. OTF are not rarely associated with a subsequent fracture-related infection (FRI), which is one of the most devastating and difficult to cure complications in orthopaedic trauma care. The aim of this study was to determine the rate and the predictive factors of FRI in OTF in a limited-resource setting of sub-Saharan Africa. MethodsPatients with OTF who underwent surgery from July 2015 to December 2020 and followed-up for at least 12 months in a tertiary care teaching hospital in Yaoundé (Cameroon) were retrospectively investigated. Diagnosis of FRI was based on the confirmatory criteria of the International FRI Consensus definition. All patients with bone infections, occurring at any time point during follow-up, were included. Logistic regression was used to determine the predictive factors for FRI. ResultsOne hundred and five patients with OTF were studied. With a mean follow-up period of 29.5 ± 16.6 months, 33 patients (31.4%) presented with FRI. Gustilo-Anderson type of OTF, compliance with antibiotics, blood transfusion, time to first washing of the wounds and method of bone fixation were factors associated with the occurrence of FRI. In multivariable logistic regression, 6-hours delay to first washing of the wounds (OR=8.07, 95% CI: 1.43–45.31, p = 0.01), and compliance with antibiotics (OR=11.33, 95%CI: 1.11–115.6, p = 0.04) were the only independent predictors of FRI. ConclusionThe overall rate of FRI in open tibial fracture is still high in the sub-Saharan African context. For similar low-resources settings, this study supports the recommendations (1) to perform a very early washing-dressing-splinting of OTF on admission of the patient, (2) to administer antibiotics early, and (3) to perform surgery as soon as reasonably possible, once appropriate personnel, equipment, implants and surgical supplies are available.

Current Concepts of Fracture-Related Infection.

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.

Diagnosis of fracture-related infection in patients without clinical confirmatory criteria: an international retrospective cohort study.

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 613fractures) 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.

Wound alpha defensin levels are significantly higher in patients with fracture related infection: A pilot, prospective cohort study

BackgroundIn absence of frank purulence, wound cultures represent ‘gold-standard’ for diagnosis of fracture related infection (FRI). However, these are time-intensive, and may be falsely negative, necessitating the need for accurate and rapid biomarker-based diagnosis. We conducted this study to determine the accuracy of 3 wound-based biomarkers for the diagnosis of FRI. MethodsThis was a prospective cohort study on adult patients who underwent an operative procedure for an upper or lower limb fracture. Wound fluid levels of alpha-defensin (AD), neutrophil elastase (NE) and IL-6 were evaluated on post-operative day 2, and patients were followed up for one month. Patients were categorized as cases (FRI) or controls (no FRI), on the basis of the consensus definition of FRI. Univariate analysis, along with receiver operating characteristic (ROC) analysis was performed. Results48 patients were included. AD levels showed a 2.6-fold elevation in cases (n = 26, Median = 23.74 µg/ml) as compared to controls (n = 22, Median = 8.78 µg/ml). The area under the curve for this variable was 0.71 (95% Confidence Intervals = 0.56 – 0.86). The levels of NE and IL-6 were not significantly different between cases and controls. ConclusionWound AD levels are significantly elevated in patients with FRI. However, these results need to be validated in a larger cohort of patients before it can be used as a biomarker of FRI.

Clinical value of bacterial culture in sinus tract in the diagnosis of fracture-related infection

Objectives: This study compared the results of bacterial culture from operation versus sinus tract samples in patients with fracture-related infection (FRI), and examined the ability of bacterial culture in sinus tract to identify pathogenic bacteria. Methods: A retrospective analysis of 53 patients with FRI from June 2016 to June 2021 was done. Common infection sites were femur, tibiofibular, hip joint, and ankle. Samples collected in sinus tract and during the operation were sent for bacterial culture. Results were summarized and compared, respectively, with pathogenic bacteria. Results: In sinus tract bacterial culture, bacteria were found in 75.6% of culture samples. The top 3 bacteria presented were: Staphylococcus aureus (32.26%), Staphylococcus epidermis (12.90%), and Pseudomonas aeruginosa (8.06%). Bacterial culture from the sinus tract matched the result of intraoperative samples 67.30% of the time, while 51.50% matched the pathogenic bacteria. Conclusion: Bacterial culture of sinus tract samples is not recommended as the basis for identifying pathogenic bacteria. Stopping antibiotic 2 weeks before operation, taking multiple samples at different sites, and sending multiple samples for bacterial culture are good ways to improve pathogen detection rate.

Single stage versus two-stage orthoplastic management of bone infection

IntroductionBone infection cases with major soft tissue loss have conventionally been treated with a staged orthoplastic approach, addressing the infection first followed by definitive management to achieve bony stability and soft tissue cover. In the last few decades, specialist centers have advocated for single stage bony stabilization with soft tissue coverage. We aimed to investigate the outcomes of patients that underwent a single stage versus a two-stage orthoplastic intervention. MethodsUsing an existing 2009–2019 database from a single major trauma centre, we identified all adults with a diagnosis of fracture related infection (FRI) or osteomyelitis (OM). The primary outcome was resolution of infection. Secondary outcomes included time to bony union, amputation, failure of orthopaedic fixation, mortality, and return to theatre. ResultsA total of 96 patients were included. 71 patients (74%) underwent a single stage procedure; out of which 61 were FRI. 25 patients (26%) underwent a two-stage procedure; out of which 24 were FRI. The average follow up for the single stage and two-stage cohorts was 32.1 and 30.3 months, respectively. Resolution of infection without the need for an amputation was achieved in 67 (94.4%) patients in the single stage cohort and in 23 (92%) patients in the two-stage cohort. When compared to the two-stage group, the single stage cohort had less recurrence of infection (9.9% versus 12%, p = 0.72), lower rates of amputation (8.5% versus 12%, p = 0.69), lower rates of failure of orthopaedic fixation (11.1% versus 13%, p = 0.82), but higher average time to bony union (15.25 months versus 12.35, p = 0.42). The differences were not statistically significant. A total of 37 patients (52.1%) had an unplanned return to theatre in the single stage compared to 12 (48%) in the two-stage cohort. In subgroup analysis of FRI cases, open fractures had a longer time to bony union when compared to closed fractures (19.7 versus 11.6 months, p = 0.01). No mortality was observed in both cohorts. ConclusionsThe single stage orthoplastic approach to bone infection is effective if planned carefully with clinical outcomes comparable to the two-stage approach. Further research should examine factors associated with unplanned return to theatre and any variation in treatment of bone infection across regions.

Treatment of FRI after intramedullary nailing of tibia fractures: assessment of nail retention and nail removal

Objectives: Fracture related infection (FRI) is a severe, potentially limb-threatening complication after fracture fixation. Dilemma exists with regard to removing or retaining implants while treating the infection. The purpose of this study was to compare primary bone union and infection clearance in patients who had an infection following intramedullary nailing of the tibia treated either by retaining the implant or by removing the implant. 
 
 Methods: Patients from two level-I trauma centers were identified through billing registries and retrospectively reviewed between January 2013 and December 2020. We identified 44 patients who had a diagnosis of FRI within 90 days of their initial fixation and returned to the OR for operative treatment of the infection. The incidences of both primary union and infection clearance were calculated for both groups and multiple parameters that may be associated with success or failure were assessed. 
 
 Results: Four patients did not have complete records and were excluded. Of the remaining patients, 20 (50%) achieved infection clearance. Twenty-three (59%) patients achieved primary union whereas 16 (41%) had a primary outcome of either delayed union, nonunion, or amputation (one additional patient excluded as healing status unknown). Further analysis showed no significant difference (X2 (39) = 1.13, p < .29) in infection clearance between patients treated with nail retention (64%) versus nail removal (68%). No significant difference was seen in primary bone union (X2 (39) = 3.24, p < .07) with 36% of patients treated with nail retention and 68% of patients treated with nail removal reaching primary union; however, this does trend toward an association. Fewer surgeries performed for infection and complication after initial fixation was positively associated with infection clearance (p < .04, M=4.6, SD=2.13, df=39) and primary union (p < .001, M=4, SD=2, df=38). 
 
 Conclusion: Infection clearance seems similarly possible with both nail retention and nail removal strategies, with fewer number of surgeries performed for infection and complication improving the likelihood of infection clearance and bone union. This may suggest that more severe FRI’s are less likely to unite and clear infection. Nail removal may play a role in increasing primary bone union; however, a larger sample size is needed for more definitive assessment.

Definition and diagnosis of fracture-related infection.

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

Musculoskeletal Infection in Orthopaedic Trauma: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection.

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.

The value of quantitative histology in the diagnosis of fracture-related infection.

This study aimed to investigate the role of quantitative histological analysis in the diagnosis of fracture-related infection (FRI). The clinical features, microbiology culture results, and histological analysis in 156 surgically treated nonunions were used to stratify the likelihood of associated infection. There were 64 confirmed infected nonunions (one or more confirmatory criteria: pus, sinus, and bacterial growth in two or more samples), 66 aseptic nonunions (no confirmatory criteria), and 26 possibly infected nonunions (pathogen identified from a single specimen and no confirmatory criteria). The histological inflammatory response was assessed by average neutrophil polymorph (NPs) counts per high-power field (HPF) and compared with the established diagnosis. Assuming a cut-off of over five neutrophils per high-power field to diagnose septic nonunion, there was 80% sensitivity and 100% specificity (accuracy 90%). Using a cut-off of no neutrophils seen in any high-power field to diagnose aseptic nonunion, there was a sensitivity of 85% and a specificity of 98% (accuracy 92%). Histology can be used in a bimodal fashion as a diagnostic test for FRI. The presence of more than five NPs/HPF had a positive predictive value for infected nonunion of 100%, while the complete absence of any NPs is almost always indicative of an aseptic nonunion (positive predictive value of 98%). Cite this article: Bone Joint J 2018;100-B:966-72.