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Vanvelk N, Van Lieshout E, Onsea J, Sliepen J, Govaert G, IJpma F, Depypere M, Ferguson J, McNally M, Obremskey W, Zalavras C, Verhofstad M, Metsemakers WJ. Diagnosis of fracture-related infection in patients without clinical confirmatory criteria: an international retrospective cohort study. J Bone Jt Infect 2023; 8:133-142. [PMID: 37123499 PMCID: PMC10134751 DOI: 10.5194/jbji-8-133-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
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 613 fractures) 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.
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Affiliation(s)
- Niels Vanvelk
- Trauma Research Unit, Department of Surgery, Erasmus MC, University
Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Esther M. M. Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University
Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven,
Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen,
Groningen, the Netherlands
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht,
Utrecht, the Netherlands
| | - Frank F. A. IJpma
- Department of Trauma Surgery, University Medical Centre Groningen,
Groningen, the Netherlands
| | - Melissa Depypere
- Department of laboratory medicine, University Hospitals Leuven,
Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory
of Clinical Bacteriology and Mycology, KU Leuven, Leuven, Belgium
| | - Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford
University Hospitals, Oxford, UK
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford
University Hospitals, Oxford, UK
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt
University Medical Center, Nashville, Tennessee, USA
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine,
University of Southern California, Los Angeles, USA
| | - Michael H. J. Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University
Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven,
Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Onsea J, Van Lieshout EMM, Zalavras C, Sliepen J, Depypere M, Noppe N, Ferguson J, Verhofstad MHJ, Govaert GAM, IJpma FFA, McNally MA, Metsemakers WJ. Validation of the diagnostic criteria of the consensus definition of fracture-related infection. Injury 2022; 53:1867-1879. [PMID: 35331479 DOI: 10.1016/j.injury.2022.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Jolien Onsea
- University Hospitals Leuven, Department of Trauma Surgery, Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Melissa Depypere
- University Hospitals Leuven, Department of laboratory medicine, Leuven, Belgium
| | - Nathalie Noppe
- University Hospitals Leuven, Department of radiology, Leuven, Belgium
| | - Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Michael H J Verhofstad
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geertje A M Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank F A IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium.
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McNally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC, Clauss M, Higuera CA, Trebše R. The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B:18-25. [PMID: 33380199 PMCID: PMC7954183 DOI: 10.1302/0301-620x.103b1.bjj-2020-1381.r1] [Citation(s) in RCA: 269] [Impact Index Per Article: 89.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition. Methods This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance. Results This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI. Conclusion The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: Bone Joint J 2021;103-B(1):18–25.
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Affiliation(s)
- Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Ricardo Sousa
- Porto Bone Infection Group (GRIP), Orthopaedic Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Antonia F Chen
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - H Charles Vogely
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martin Clauss
- Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic, Florida, USA
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