Search

Aim: To identify the most relevant factors with respect to the management of fracture-related infection (FRI) and to develop a comprehensive FRI classification that guides decision-making and allows scientific comparison., Method: An international group of FRI experts determined the preconditions, purpose, primary factors for inclusion, format and detailed description of the elements of an FRI classification through a consensus driven process., Results: Three major elements were identified and grouped together in the FRI Classification: Fracture (F), Related patient factors (R) and Impairment of soft tissues (I). Each element was divided into five levels of complexity. Fractures can be healed (F1) or unhealed (F2-5). Patients may be fully healthy (R1) or have 4 levels of compromise, with and without end-organ damage (R2-5). Soft tissue condition ranges from well vascularized and easily closed (I1) to major skin defects requiring free flaps (I4). In all three elements, the fifth level (F5, R5 or I5) describes a patient who has an unreconstructible bone, soft tissue envelope or is not fit for surgery., Conclusion: The FRI classification, which is based on the three major elements Fracture (F), Related patient factors (R) and Impairment of soft tissues (I) is intended to guide decision-making and improve the quality of scientific reporting for FRIs in the future. The proposed classification is based on expert opinion and therefore an essential next step is clinical validation, in order to realize the ultimate goal of improving outcomes in the management of FRI., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Introduction: Fracture related infection (FRI) may be a devastating complication of open tibial shaft fractures. We sought to determine if antibiotic bead pouch, negative pressure wound therapy, or negative pressure wound therapy over antibiotic beads as the initial coverage method for type IIIB open tibial shaft fractures is associated with risk of FRI., Patients and Methods: Retrospective cohort study with radiograph and chart review of patients aged ≥16 years with isolated, displaced, extra-articular, Gustilo-Anderson type IIIB open diaphyseal AO/OTA 42 tibial fractures requiring rotational or free tissue transfer for soft tissue coverage at one Level 1 trauma center between 2007 and 2020. An association of dressing applied at the first surgical debridement (application of antibiotic bead pouch, negative pressure wound therapy, or combined therapy) with a primary outcome of FRI requiring debridement or amputation was analyzed by multivariable logistic regression considering demographic, injury, and treatment characteristics., Results: 113 patients met eligibility criteria. Median follow-up was 33 months (interquartile range 5-88). 41 patients were initially treated with NPWT, 59 with ABP, and 13 with ABP+NPWT at the initial surgical debridement. 39 (35%) underwent subsequent debridement or amputation for FRI. One amputation occurred in the ABP group for refractory deep surgical site infection (p = 0.630). Initial wound management with an antibiotic bead pouch versus either negative pressure wound therapy alone or negative pressure wound therapy combined with an antibiotic bead pouch was associated with lower odds of debridement or amputation for FRI (β = -1.08, 95% CI -2.00 to -0.17, p = 0.02)., Conclusions: In our retrospective analysis, antibiotic bead pouch for initial coverage of type IIIB open tibial shaft fractures requiring flap coverage was associated with a lower risk of FRI requiring debridement or amputation than negative pressure wound therapy applied with or without antibiotic beads. A prospective clinical trial is warranted., Competing Interests: Declaration of Competing Interest JTP reports research support from AO North America. CZ reports participation on an editorial or governing board for Clinical Orthopaedics and Related Research and Journal of Orthopaedic Trauma., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

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., Competing Interests: Conflict of interest All authors declare no conflict of interest with respect to the preparation and writing of this article., (Copyright © 2022. Published by Elsevier Ltd.)

Bone healing is a complicated process of tissue regeneration that is influenced by multiple biological and biomechanical processes. In a minority of cases, these physiological processes are complicated by issues such as nonunion and/or fracture-related infection (FRI). Based on a select few in vivo experimental animal studies, construct stability is considered an important factor influencing both prevention and treatment of FRI. Stephan Perren played a pivotal role in the evolution of our current understanding of the critical relationship between biomechanics, fracture healing and infection. Furthermore, his concept of strain theory and the process of fracture healing is familiar to several generations of surgeons and has influenced implant development and design for the past 50 years. In this review we describe the role of biomechanical stability on fracture healing, and provide a detailed analysis of the preclinical studies addressing this in the context of FRI. Furthermore, we demonstrate how Perren's concepts of stability are still applied to current surgical techniques to aid in the prevention and treatment of FRI. Finally, we highlight the key knowledge gaps in the underlying basic research literature that need to be addressed as we continue to optimize patient care., Competing Interests: Declaration of Competing Interest All authors declare no conflict of interest with respect to the preparation and writing of this article., (Copyright © 2020. Published by Elsevier Ltd.)

Introduction: Open fractures are still a challenge in orthopaedic trauma surgery, and compared to closed fractures, the rate of complications including fracture-related infection (FRI) remains significantly higher. Although different guidelines on prevention of FRI have been published in past decades, the current recommendations vary significantly. The objectives of this international questionnaire were to evaluate clinical practice procedures for the prevention of FRI in open fractures and to evaluate adherence to available guidelines., Methods: A 17-item questionnaire regarding prophylaxis against infection in fracture care was administered by SurveyMonkey® and was sent via blast e-mail to all users of AOTrauma (Davos, Switzerland)., Results: Overall, 1197 orthopaedic trauma surgeons answered the survey. Although cephalosporins were the most commonly prescribed agents for perioperative antibiotic prophylaxis (PAP) in open fractures, a total of 13 different antibiotics were mentioned in the survey. Furthermore, the duration of PAP was extremely variable with a tendency towards longer treatment periods with increasing open fracture severity. The majority of surgeons (71%) agreed that the optimal duration of PAP was not well defined in the literature. The use of local anti-infective agents varied significantly, although all options received additional votes with increasing injury severity. Some of the other surgical aspects addressed in this review were associated with debridement and irrigation. A delay of six hours from injury to the first debridement was acceptable to 47% of surgeons, but delays were tolerable. Normal saline was the solution used most often for wound irrigation in open fractures (89%), with low-pressure irrigation being applied most commonly (55%)., Conclusions: This international survey provided an overview of clinical practice in FRI prevention, particularly in open fracture cases. The treatment of these serious injuries remains heterogeneous. A major issue is the lack of consensus concerning type and duration of PAP. Furthermore, there seems to be no agreement on the indication for the use of local anti-infective agents. Overall, it is unknown what the repercussions are of this lack of internationally accepted guidelines on daily clinical practice, but it is clear that standardised treatment protocols are preferable in the current medical landscape., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Controversy exists on the relationship between intramedullary nailing (IMN) and the timing of fixation in the development of respiratory failure (RF) following femoral fractures. The purpose of this study is to identify risk factors for RF and evaluate the role of multiple IMN in the above setting. We prospectively observed 126 consecutive patients with femoral fractures for the development of RF. Twenty-one patients (17%) developed RF. This occurred before fracture fixation in 11 patients and after IMN in 10 patients; five after multiple IMN and five after a single IMN procedure. Patients who underwent multiple IMN demonstrated a significant increase of RF after fracture fixation (5/8,) compared to patients with one IMN procedure (5/114, 4.4%, p<0.001). Stepwise regression analysis identified two independent RF risk factors: thoracic injury and multiple IMN (odds ratios: 40.6 and 25.6, respectively). Thoracic injury and multiple IMN procedures are independent risk factors for RF in patients with femoral fractures, and the combination of the above conditions is highly predictive of the development of RF.