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Arch Orthop Trauma Surg. 2019 Oct 29. doi: 10.1007/s00402-019-03287-4. [Epub ahead of print]

General treatment principles for fracture-related infection: recommendations from an international expert group.

Author information

1
Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium. willem-jan.metsemakers@uzleuven.be.
2
Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.
3
Department of Infectious Diseases, Gustave Dron Hospital, University of Lille, Lille, France.
4
Orthopedic Department of Septic Surgery, Orthopaedic-Trauma Unit, Department for the Musculoskeletal System, CHUV, Lausanne, Switzerland.
5
Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands.
6
Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.
7
Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium.
8
AO Research Institute Davos, Davos, Switzerland.
9
Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.
10
Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
11
Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, USA.
12
Department of Trauma Surgery, University Hospital of Münster, Münster, Germany.
13
The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.
14
Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA.

Abstract

Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients' short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.Level of evidence: Level V.

KEYWORDS:

Diagnosis; Fracture; Fracture-related infection; Infection; Outcome; Treatment

PMID:
31659475
DOI:
10.1007/s00402-019-03287-4

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