Fracture-related Infection Research Articles

Validation of the diagnostic criteria of the consensus definition of fracture-related infection

BackgroundThe 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. MethodsA 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. ResultsOverall, 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. ConclusionsThe 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.

Isavuconazole in the Treatment of Aspergillus fumigatus Fracture-Related Infection: Case Report and Literature Review.

Aspergillus fracture-related infection (FRI) is a rare, but severe complication in trauma surgery. The optimal antifungal treatment for Aspergillus osteomyelitis, including FRI, has not been established yet, as only cases have been documented and data on bone penetration of antifungal drugs are scarce. We describe a patient with Aspergillus fumigatus FRI of the tibia who was treated with isavuconazole after developing liver function disturbances during voriconazole therapy. Isavuconazole, the active moiety formed after hydrolysis of the prodrug isavuconazonium sulfate by plasma esterases, was administered in a maintenance dose of 200 mg q24 h, followed by 150 mg q24 h. The patient completed a six-month antifungal treatment course. Although fracture union was not achieved during six months of follow-up after therapy cessation, no confirmatory signs of FRI were observed. Additionally, two literature searches were conducted to review available data on antifungal treatment of Aspergillus osteomyelitis and bone penetration of antifungals. One hundred and eight cases of Aspergillus osteomyelitis, including six (5.6%) FRI cases, were identified. Voriconazole and (lipid formulations of) amphotericin B were the most commonly used antifungals. In three (2.8%) cases isavuconazole was prescribed as salvage therapy. Data on antifungal bone penetration were reported for itraconazole, voriconazole, amphotericin B, anidulafungin and 5-fluorocytosin. Isavuconazole might be a promising alternative for the treatment of Aspergillus osteomyelitis. However, standardized case documentation is needed to evaluate the efficacy of isavuconazole and other antifungals in the treatment of Aspergillus osteomyelitis, including FRI.

Duration of Perioperative Antibiotic Prophylaxis in Open Fractures: A Systematic Review and Critical Appraisal.

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.

What Is the Most Effective Empirical Antibiotic Treatment for Early, Delayed, and Late Fracture-Related Infections?

Antibiotic treatment strategies for fracture-related infections (FRI) are often extrapolated from periprosthetic joint infections (PJI), although, in contrast to PJI, detailed analysis of pathogens and their antibiotic resistance is missing. Therefore, this study aimed to investigate antibiotic susceptibility profiles to identify effective empiric antibiotic treatment for early-, delayed-, and late-onset FRI. Patients treated for FRI from 2013 to 2020 were grouped into early (<2 weeks), delayed (3–10 weeks), and late (>10 weeks) onset of infection. Antibiotic susceptibility profiles were examined with respect to broadly used antibiotics and antibiotic combinations. In total, 117 patients (early n = 19, delayed n = 60, late n = 38) were enrolled. In early-onset FRI, 100.0% efficacy would be achieved by meropenem + vancomycin, gentamicin + vancomycin, co-amoxiclav + glycopeptide, ciprofloxacin + glycopeptide and piperacillin/tazobactam + glycopeptide. For patients with delayed FRI, the highest susceptibility was revealed for meropenem + vancomycin, gentamicin + vancomycin and ciprofloxacin + glycopeptide (96.7%). Meropenem + vancomycin was the most effective empiric antimicrobial in patients with late-onset of infection with 92.1% coverage. No subgroup differences in antibiotic sensitivity profiles were observed except for the combination ciprofloxacin + glycopeptide, which was significantly superior in early FRI (F = 3.304, p = 0.04). Across all subgroups meropenem + vancomycin was the most effective empiric treatment in 95.7% of patients with confirmed susceptibility. Meropenem + vancomycin, gentamicin + vancomycin, co-amoxiclav + glycopeptide are the best therapeutic options for FRI, regardless of the onset of infection. To avoid multidrug resistance, established antibiotic combinations such as co-amoxiclav with a glycopeptide seem to be reasonable as a systemic antibiotic therapy, while vancomycin + gentamicin could be implemented in local antibiotic therapy to reduce adverse events during treatment.

Vitamin D Receptor Genetic Variations May Associate with the Risk of Developing Late Fracture-Related Infection in the Chinese Han Population.

Variations in the vitamin D receptor (VDR) gene are related to several inflammatory disorders. However, the potential links between such alternations and the risk of developing late fracture-related infection (FRI) remain unclear. This study investigated associations between genetic variations in the VDR and susceptibility to late FRI in the Chinese Han population. Between January 2016 and December 2019, 336 patients with late FRI and 368 healthy controls were genotyped six VDR genetic variations, including ApaI (rs7975232), BsmI (rs1544410), FokI (rs2228570), TaqI (rs731236), GATA (rs4516035), and Cdx-2 (rs11568820). Significant associations were observed between rs7975232 and FRI susceptibility in the recessive (P = 0.019, OR = 0.530, 95% CI 0.310–0.906) model. Patients with AA genotype had a relatively higher level of serological vitamin D (20.6 vs. 20.3 vs. 17.9 ng/ml) (P = 0.021) than those of AC and CC genotypes. Although no statistical differences were observed, potential correlations may exist between rs1544410 (dominant model: P = 0.079, OR = 0.634), rs2228570 (dominant model: P = 0.055, OR = 0.699), and rs4516035 (dominant model: P = 0.065, OR = 1.768) and the risk of FRI development. In the Chinese cohort, ApaI was associated with a decreased risk of developing FRI, and patients with the AA genotype had a higher vitamin D level. Further studies are required to assess the role of genetic variations in BsmI, FokI, and GATA in the pathogenesis of late FRI.

Fracture-related infection in osteoporotic bone causes more severe infection and further delays healing.

AimsWith the ageing population, fragility fractures have become one of the most common conditions. The objective of this study was to investigate whether microbiological outcomes and fracture-healing in osteoporotic bone is worse than normal bone with fracture-related infection (FRI).MethodsA total of 120 six-month-old Sprague-Dawley (SD) rats were randomized to six groups: Sham, sham + infection (Sham-Inf), sham with infection + antibiotics (Sham-Inf-A), ovariectomized (OVX), OVX + infection (OVX-Inf), and OVX + infection + antibiotics (OVX-Inf-A). Open femoral diaphysis fractures with Kirschner wire fixation were performed. Staphylococcus aureus at 4 × 104 colony-forming units (CFU)/ml was inoculated. Rats were euthanized at four and eight weeks post-surgery. Radiography, micro-CT, haematoxylin-eosin, mechanical testing, immunohistochemistry (IHC), gram staining, agar plating, crystal violet staining, and scanning electron microscopy were performed.ResultsAgar plating analysis revealed a higher bacterial load in bone (p = 0.002), and gram staining showed higher cortical bone colonization (p = 0.039) in OVX-Inf compared to Sham-Inf. OVX-Inf showed significantly increased callus area (p = 0.013), but decreased high-density bone volume (p = 0.023) compared to Sham-Inf. IHC staining showed a significantly increased expression of TNF-α in OVX-Inf compared to OVX (p = 0.049). Significantly reduced bacterial load on bone (p = 0.001), enhanced ultimate load (p = 0.001), and energy to failure were observed in Sham-Inf-A compared to Sham-Inf (p = 0.028), but not in OVX-Inf-A compared to OVX-Inf.ConclusionIn osteoporotic bone with FRI, infection was more severe with more bone lysis and higher bacterial load, and fracture-healing was further delayed. Systemic antibiotics significantly reduced bacterial load and enhanced callus quality and strength in normal bone with FRI, but not in osteoporotic bone.Cite this article: Bone Joint Res 2022;11(2):49–60.

Bacteria-targeted fluorescence imaging of extracted osteosynthesis devices for rapid visualization of fracture-related infections

PurposeFracture-related infection (FRI) is a serious complication in orthopedic trauma surgery worldwide. Especially, the distinction of infection from sterile inflammation and the detection of low-grade infection are highly challenging. The objective of the present study was to obtain proof-of-principle for the use of bacteria-targeted fluorescence imaging to detect FRI on extracted osteosynthesis devices as a step-up towards real-time image-guided trauma surgery.MethodsExtracted osteosynthesis devices from 13 patients, who needed revision surgery after fracture treatment, were incubated with a near-infrared fluorescent tracer composed of the antibiotic vancomycin and the fluorophore IRDye800CW (i.e., vanco-800CW). Subsequently, the devices were imaged, and vanco-800CW fluorescence signals were correlated to the results of microbiological culturing and to bacterial growth upon replica plating of the imaged devices on blood agar.ResultsImportantly, compared to culturing, the bacteria-targeted fluorescence imaging of extracted osteosynthesis devices with vanco-800CW allows for a prompt diagnosis of FRI, reducing the time-to-result from days to less than 30 min. Moreover, bacteria-targeted imaging can provide surgeons with real-time visual information on the presence and extent of infection.ConclusionHere, we present the first clinical application of fluorescence imaging for the detection of FRI. We conclude that imaging with vanco-800CW can provide early, accurate, and real-time visual diagnostic information on FRI in the clinical setting, even in the case of low-grade infections.Graphical abstract

The intersection of fracture healing and infection: Orthopaedics research society workshop 2021.

Infection is a common cause of impaired fracture healing. In the clinical setting, definitive fracture treatment and infection are often treated separately and sequentially, by different clinical specialties. The ability to treat infection while promoting fracture healing will greatly reduce the cost, number of procedures, and patient morbidity associated with infected fractures. In order to develop new therapies, scientists and engineers must understand the clinical need, current standards of care, pathologic effects of infection on fractures, available preclinical models, and novel technologies. One of the main causes of poor fracture healing is infection; unfortunately, bone regeneration and infection research are typically approached independently and viewed as two separate disciplines. Here, we aim to bring these two groups together in an educational workshop to promote research into the basic and translational science that will address the clinical challenge of delayed fracture healing due to infection. Statement of clinical significance: Infection and nonunion are each feared outcomes in fracture care, and infection is a significant driver of nonunion. The impact of nonunions on patie[Q2]nt well-being is substantial. Outcome data suggests a long bone nonunion is as impactful on health-related quality of life measures as a diagnosis of type 1 diabetes and fracture-related infection has been shown to significantly l[Q3]ower a patient's quality of life for over 4 years. Although they frequently are associated with one another, the treatment approaches for infections and nonunions are not always complimentary and cannot be performed simultaneously without accepting tradeoffs. Furthermore, different clinical specialties are often required to address the problem, the orthopedic surgeon treating the fracture and an infectious disease specialist addressing the sources of infection. A sequential approach that optimizes treatment parameters requires more time, more surgeries, and thus confers increased morbidity to the patient. The ability to solve fracture healing and infection clearance simultaneously in a contaminated defect would benefit both the patient and the health care system.

Analyzing risk factors for treatment failure in fracture-related infection.

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. 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. 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). 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. Retrospective cohort study; Level III.

Combination of pre-adapted bacteriophage therapy and antibiotics for treatment of fracture-related infection due to pandrug-resistant Klebsiella pneumoniae

A 30-year-old bombing victim with a fracture-related pandrug-resistant Klebsiella pneumoniae infection after long-term (>700 days) antibiotic therapy is treated with a pre-adapted bacteriophage along with meropenem and colistin, followed by ceftazidime/avibactam. This salvage therapy results in objective clinical, microbiological and radiological improvement of the patient’s wounds and overall condition. In support, the bacteriophage and antibiotic combination is highly effective against the patient’s K. pneumoniae strain in vitro, in 7-day mature biofilms and in suspensions.

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.

Intramedullary application of local antibiotic bullets for the treatment of long bone fracture related infection.

The optimal means of local antibiotic delivery for fracture related infection is unknown. Until now, intramedullary application of calcium sulphate based local antibiotics has been challenging. We report on the use of a newly available mode of preparation and delivery: the Stimulan Bullet Mat and Introducer (Biocomposites Ltd, Staffordshire, England). A retrospective analysis of prospectively collected data for infection cases at two separate tertiary referral institutions was performed. We included cases of long bone FRI with a retained intramedullary nail, treated with a single stage protocol of metalwork removal, debridement, local antibiotic application using the novel mould and applicator, with additional bony stabilisation and soft tissue reconstruction where required. All 13 patients achieved infection remission rate with an average follow-up of 19.7months (range 12-28). All 6 patients with infection around an unhealed fracture achieved union at an average 8months (range 4-12) from debridement. No patients developed aseptic wound leak. Antibiotic impregnated calcium sulphate can be used safely as part of a single stage treatment protocol for the treatment of long bone fracture related infection following intramedullary nailing. We have demonstrated high rates of infection remission and union, using a newly available intramedullary applicator.

Risk Factors for Gram-Negative Fracture-Related Infection.

In this study, we evaluated risk factors for gram-negative fracture-related infection in a mixed cohort of gram-positive and gram-negative fracture-related infections to guide perioperative antibiotic prophylaxis for surgical fixation of fractures. We performed a retrospective review of all patients with fracture who were treated at an urban academic level I trauma center between February 1, 2012, and June 30, 2017. Inclusion criteria were as follows: (1) open or closed fracture with internal fixation; (2) deep, acute to subacute (<6 weeks), culture-positive fracture-related infection; and (3) age 18 years or older. Infections were classified as gram positive, gram negative, or polymicrobial. Demographic, surgical, and postoperative characteristics were compared among groups. Of 3360 patients, 43 (1.3%) had a fracture-related infection (15 gram negative, 14 gram positive, and 14 polymicrobial). Risk factors for gram-negative infection included initial external fixation (P=.038), the need for soft tissue coverage of an open fracture site (P=.039), lower albumin level at the time of infection (P=.005), and hospitalization for longer than 10 days (P=.018). Perioperative gram-negative antibiotic prophylaxis for fracture fixation surgery should be considered for those who have been staged with external fixation, require soft tissue coverage, are at risk for malnutrition in the postoperative period, and have prolonged inpatient hospitalization. [Orthopedics. 2022;45(2):91-96.].

Effectiveness of an Online Course on Fracture-Related Infections

ABSTRACT This study aims to evaluate the effectiveness of an online course to enable orthopaedic surgeons to acquire the core competencies necessary to prevent and treat fracture-related infections (FRI). This study included orthopaedic surgeons and residents from Latin American countries who attended an online course focused on FRI. The online course included: didactic lectures, small-group clinical case discussions, and panel case discussions. The course was delivered using Zoom® platform and designed to address four core competencies: prevention, definition and diagnosis, antimicrobial therapy, and surgical treatment. An online questionnaire was created distributing 16 questions through six clinical scenarios. Participants were invited to answer the questionnaire before and after the course. Sixty of the 78 course participants answered the pre-course, and 42 the post-course assessment. Relative to before the course, the mean post-course assessment score rose significantly for prevention of FRI (4.1 before and 4.5 after; p = 0.014), definition and diagnosis (2.4 before and 3.4 after; p = 0.001), and surgical treatment (2.2 before and 2.8 after; p = 0.011). The final score encompassing all four core competencies also rose significantly (2.7 before and 3.3 after; p = 0.001). The online course on FRI was feasible and effective, significantly increasing course users’ knowledge of overall competency in managing FRI.

Continuous local antibiotic perfusion: A treatment strategy that allows implant retention in fracture-related infections

Fracture-related infections are difficult to treat because of the formation of biofilms around implants. Systemic antibiotics are notoriously ineffective against biofilms due to their insufficient penetration of tissues with poor vascularity. The goal of treating fracture-related infections is to achieve bone union while retaining the implant. Our proposal of continuous local antibiotic perfusion is a sustained local delivery system of sufficient antibiotics to bone and soft tissue infection sites, including to bone marrow via needles as intra-medullary antibiotics perfusion and to soft-tissue via double-lumen subcutaneous tubes as intra-soft tissue perfusion. In this study, we examined the outcomes of 40 patients treated for fracture-related infections using continuous local antibiotic perfusion between 2015 and 2021 at Steel Memorial Hirohata Hospital, Himeji, Japan. The antibiotic used for continuous local antibiotic perfusion was gentamicin in all cases. Implant removal was required in five patients. Two patients required toe amputation and knee arthrodesis, while the remaining 38 patients achieved fracture union. Only one case of transient acute renal injury as a systemic side effect was observed, but it soon resolved. The blood concentration of gentamicin could be adjusted to less than the trough level. Continuous local antibiotic perfusion is a novel local drug delivery system that has the potential of delivering sufficient concentrations of antibiotics with few systemic side effects; it is a useful option for the treatment of fracture-related infections.

Multidisciplinary approach to fracture-related infection

Fracture-related infection is a feared complication of trauma surgery with potentially major repercussions on quality of life and healthcare systems. Its management is based on two pillars: a radical surgical debridement along with a targeted long-term antibiotic therapy based on multiple deep tissue samples obtained during the chosen surgical procedure. Multidisciplinary management and early diagnosis are essential for treatment success. The implementation of a standardized definition for fracture-related infections since 2018 has allowed the optimization and streamlining of management algorithms and their validation in the literature. This article provides a comprehensive and in-depth review of recent advances in the diagnosis and management of fracture-related infections.

Outcome and Risk Factors for Recurrence of Early Onset Fracture-Related Infections in a Large Retrospective Multicentre Cohort Study

Outcome and Risk Factors for Recurrence of Early Onset Fracture-Related Infections in a Large Retrospective Multicentre Cohort Study

Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect

IntroductionManaging critical-sized tibial defects is one of the most complex challenges orthopedic surgeons face. This is even more problematic in the presence of infection and soft-tissue loss. The purpose of this study is to describe a comprehensive three-stage surgical protocol for the reconstruction of infected tibial injuries with combined bone defects and soft-tissue loss, and report the clinical outcomes.Materials and methodsA retrospective study at a specialized limb reconstruction center identified all patients with infected tibial injuries with bone and soft-tissue loss from 2010 through 2018. Thirty-one patients were included. All cases were treated using a three-stage protocol: (1) infected limb damage control; (2) soft-tissue coverage with a vascularized or local flap; (3) definitive bone reconstruction using distraction osteogenesis principles with external fixation. Primary outcomes: limb salvage rate and infection eradication. Secondary outcomes: patient functional outcomes and satisfaction.ResultsPatients in this series of chronically infected tibias had been operated upon 3.4 times on average before starting our limb salvage protocol. The mean soft-tissue and bone defect sizes were 124 cm2 (6–600) and 5.4 cm (1–23), respectively. A free flap was performed in 67.7% (21/31) of the cases; bone transport was the selected bone-reconstructive option in 51.7% (15/31). Local flap failure rate was 30% (3/10), with 9.5% for free flaps (2/21). Limb salvage rate was 93.5% (29/31), with infection eradicated in all salvaged limbs. ASAMI bone score: 100% good/excellent. Mean VAS score was 1.0, and ASAMI functional score was good/excellent in 86% of cases. Return-to-work rate was 83%; 86% were “very satisfied” with the treatment outcome.ConclusionA three-stage surgical approach to treat chronically infected tibial injuries with combined bone and soft-tissue defects yields high rates of infection eradication and successful limb salvage, with favorable functional outcomes and patient satisfaction.

Management of fracture-related infections

Fracture-related infections (FRI) are amajor 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.

Fracture-related infections after intramedullary nailing : Diagnostics and treatment

Intramedullary nailing is the treatment of choice for alarge 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 asufficient debridement of the nail is impossible due to its intramedullary location. In chronic FRI after intramedullary nailing aone-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, aone-stage procedure with nail exchange should be preferred. If achronic infection with soft tissue and bone defects develops after intramedullary nailing, atwo-stage procedure analogous to the treatment of osteomyelitis should be considered. In this case amultidisciplinary 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.