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Hackl S, von Rüden C, Trenkwalder K, Keppler L, Hierholzer C, Perl M. Long-Term Outcomes Following Single-Stage Reamed Intramedullary Exchange Nailing in Apparently Aseptic Femoral Shaft Nonunion with Unsuspected Proof of Bacteria. J Clin Med 2024; 13:1414. [PMID: 38592249 PMCID: PMC10933962 DOI: 10.3390/jcm13051414] [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: 02/14/2024] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The aim of this study was to evaluate detection rates and risk factors for unsuspected proof of bacteria, as well as clinical and radiologic outcomes following femoral shaft nonunion without clinical signs of infection treated by a single-stage surgical revision procedure including reamed intramedullary exchange nailing. Methods: A retrospective cohort study was performed in a European level I trauma center between January 2015 and December 2022. Fifty-eight patients were included who underwent reamed intramedullary exchange nailing as a single-step procedure for surgical revision of posttraumatic diaphyseal femoral nonunion without any indications of infection in medical history and without clinical signs of local infection. Clinical details of the patients were analyzed and functional and radiologic long-term outcomes were determined. Results: In all patients, with and without proof of bacteria osseous, healing could be observed. The physical component summary of the SF-12 demonstrated significantly better results at least one year after the final surgical revision in case of a negative bacterial culture during exchange nailing. Conclusions: Clinical long-term outcomes demonstrated a trend towards better results following femoral shaft nonunion revision if there was no evidence for the presence of low-grade infected nonunion. In this case, a single-stage surgical procedure may be recommended.
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Affiliation(s)
- Simon Hackl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christian von Rüden
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Department of Trauma Surgery, Orthopedics and Hand Surgery, Weiden Medical Center, 92637 Weiden, Germany
| | - Katharina Trenkwalder
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute for Biomechanics, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Lena Keppler
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Christian Hierholzer
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Mario Perl
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
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Hackl S, Eijkenboom A, Militz M, von Rüden C. [Diagnostic and therapeutic work-up of infected tibial nonunion]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:96-102. [PMID: 37812233 DOI: 10.1007/s00113-023-01371-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The failure of bone fracture healing is one of the major complications of fracture treatment, especially of the tibia due to its limited soft tissue coverage and high rate of open injuries. Although implant development is constantly progressing and modern surgical techniques are continuously improving, infected tibial nonunion plays a decisive role in terms of its variable clinical presentation. OBJECTIVE This article provides guidelines for the successful surgical treatment of infected tibial nonunion. MATERIAL AND METHOD Strategies are presented to identify infection as a cause of failure of fracture healing and to achieve infection and bone healing. RESULTS A significant amount of tibial nonunions primarily thought to be aseptic ultimately turn out to be infected nonunions. CONCLUSION The treatment of infected tibial nonunion requires extensive clinical, radiological and laboratory diagnostics as well as a profound biomechanical and biological understanding of the bone situation. This is the only way to achieve rapid osseous healing with as few revision interventions as possible.
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Affiliation(s)
- Simon Hackl
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
| | - Alexander Eijkenboom
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Matthias Militz
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Christian von Rüden
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Weiden, Weiden, Deutschland
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Rupp M, Walter N, Bärtl S, Heyd R, Hitzenbichler F, Alt V. Fracture-Related Infection-Epidemiology, Etiology, Diagnosis, Prevention, and Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:17-24. [PMID: 37970721 PMCID: PMC10916768 DOI: 10.3238/arztebl.m2023.0233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 10/23/2023] [Accepted: 10/23/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Fracture-related infection (FRI) is a challenge to physicians and other workers in health care. In 2018, there were 7253 listed cases of FRI in Germany, corresponding to an incidence of 10.7 cases per 100 000 persons per year. METHODS This review is based on pertinent publications retrieved from a search in PubMed with the search terms "fracture," "infection," "guideline," and "consensus." Aside from the primary literature, international guidelines and consensus recommendations were evaluated as well. RESULTS FRI arise mainly from bacterial contamination of the fracture site. Staphylococcus aureus is the most commonly detected pathogen. The treatment is based on surgery and antibiotics and should be agreed upon by an interdisciplinary team; it is often difficult because of biofilm formation. Treatment options include implant-preserving procedures and single-stage, two-stage, or multi-stage implant replacement. Treatment failure occurs in 10.3% to 21.4% of cases. The available evidence on the efficacy of various treatment approaches is derived mainly from retrospective cohort studies (level III evidence). Therefore, periprosthetic joint infections and FRI are often discussed together. CONCLUSION FRI presents an increasing challenge. Preventive measures should be optimized, and the treatment should always be decided upon by an interdisciplinary team. Only low-level evidence is available to date to guide diagnostic and treatment decisions. High-quality studies are therefore needed to help us meet this challenge more effectively.
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Affiliation(s)
- Markus Rupp
- These authors share first authorship
- Department for Trauma surgery, University Hospital Regensburg, Germany
| | - Nike Walter
- These authors share first authorship
- Department for Trauma surgery, University Hospital Regensburg, Germany
| | - Susanne Bärtl
- Department for Trauma surgery, University Hospital Regensburg, Germany
| | - Robert Heyd
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Germany
| | - Florian Hitzenbichler
- Department for Hospital hygiene and Infectiology, University Hospital Regensburg, Germany
| | - Volker Alt
- Department for Trauma surgery, University Hospital Regensburg, Germany
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Hackl S, Trenkwalder K, Militz M, Augat P, Stuby FM, von Rüden C. [Infected nonunion: diagnostic and therapeutic work-up]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:602-610. [PMID: 35750886 DOI: 10.1007/s00113-022-01204-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Septic nonunion is one of the major complications in fracture healing. The challenge is to identify the infection as the cause of nonunion first and then to achieve healing of the infection and the bone. OBJECTIVE Because of the more heterogeneous appearance of an infected nonunion, the prevalence of germ detection in surgical nonunion revision is often underestimated. MATERIAL AND METHODS In a retrospective study between 2010 and 2017, 86 patients with radiologically confirmed femoral shaft nonunion without clinical evidence and unremarkable medical history of a florid infection as the cause of nonunion, who had undergone primary single-stage surgical nonunion revision were analyzed. At least four intraoperatively obtained samples were evaluated for microbiological diagnosis. A distinction was made between tissue samples with subsequent 48‑h short-term incubation and tissue samples with 14-day long-term cultivation. The finding "germ detection" was made if at least two of the samples demonstrated bacterial growth. RESULTS In 18 of 86 patients with a nonunion preoperatively judged to be aseptic, positive bacterial evidence was obtained after short-term incubation. After long-term cultivation, positive bacterial detection was possible in 38 of 86 patients with a femoral shaft nonunion initially classified as aseptic. Regarding potential risk factors, the two groups demonstrated no relevant differences. In 29 patients, 1 pathogen was isolated from the obtained samples, whereas in the remaining 9 patients, a mixed culture with an average of 2.9 ± 0.5 different bacteria was detected. Identification revealed mainly low-virulence bacteria, most commonly Staphylococcus epidermidis. CONCLUSION If the preoperative diagnostics including clinical, laboratory and radiological examination as well as a careful anamnesis reveal indications of a possible infectious event, the surgical nonunion revision should be performed in two stages with specimen collection before definitive nonunion revision. For microbiological diagnosis, several representative tissue samples should independently be obtained from the nonunion site and incubated for 14 days. Only in the absence of evidence of septic nonunion is a single-stage procedure suggested.
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Affiliation(s)
- Simon Hackl
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
| | - Katharina Trenkwalder
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Matthias Militz
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Peter Augat
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Fabian M Stuby
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Christian von Rüden
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
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Baertl S, Walter N, Engelstaedter U, Ehrenschwender M, Hitzenbichler F, Alt V, Rupp M. What Is the Most Effective Empirical Antibiotic Treatment for Early, Delayed, and Late Fracture-Related Infections? Antibiotics (Basel) 2022; 11:287. [PMID: 35326751 PMCID: PMC8944514 DOI: 10.3390/antibiotics11030287] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Susanne Baertl
- Department for Trauma Surgery, University Hospital, 93053 Regensburg, Germany; (S.B.); (N.W.); (U.E.); (V.A.)
| | - Nike Walter
- Department for Trauma Surgery, University Hospital, 93053 Regensburg, Germany; (S.B.); (N.W.); (U.E.); (V.A.)
- Department for Psychosomatic Medicine, University Hospital, 93053 Regensburg, Germany
| | - Ulrike Engelstaedter
- Department for Trauma Surgery, University Hospital, 93053 Regensburg, Germany; (S.B.); (N.W.); (U.E.); (V.A.)
| | - Martin Ehrenschwender
- Institute of Laboratory Medicine, Microbiology and Hygiene, Hospital of the Order of St. John, 93053 Regensburg, Germany;
| | - Florian Hitzenbichler
- Department of Infection Prevention and Infectious Diseases, University Hospital, 93053 Regensburg, Germany;
| | - Volker Alt
- Department for Trauma Surgery, University Hospital, 93053 Regensburg, Germany; (S.B.); (N.W.); (U.E.); (V.A.)
| | - Markus Rupp
- Department for Trauma Surgery, University Hospital, 93053 Regensburg, Germany; (S.B.); (N.W.); (U.E.); (V.A.)
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