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Thompson E, Qureshi A. Pathogens in FRI - Do bugs matter? - An analysis of FRI studies to assess your enemy. J Orthop 2024; 53:59-72. [PMID: 38476676 PMCID: PMC10925936 DOI: 10.1016/j.jor.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/09/2024] [Indexed: 03/14/2024] Open
Abstract
Fracture-related infection (FRI) is a devasting complication for both patients and their treating Orthopaedic surgeon that can lead to loss of limb function or even amputation. The unique and unpredictable features of FRI make its diagnosis and treatment a significant challenge. It has substantial morbidity and financial implications for patients, their families and healthcare providers. In this article, we perform an in-depth and comprehensive review of FRI through recent and seminal literature to highlight evolving definitions, diagnostic and treatment approaches, focusing on common pathogens such as Staphylococcus aureus, polymicrobial infections and multi-drug-resistant organisms (MDRO). Furthermore, multiple resistance mechanisms and adaptations for microbial survival are discussed, as well as modern evidence-based medical and surgical advancements in treatment strategies in combating FRI.
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Affiliation(s)
- Emmet Thompson
- Limb Reconstruction Service, Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Amir Qureshi
- Limb Reconstruction Service, Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
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Gross EG, Mohammed Z, Carter KJ, Benson EM, McGwin G, Mihas A, Atkins AC, Spitler CA, Johnson JP. The Impact of Smoking on Hospital Course and Postoperative Outcomes in Patients With Fracture-Related Infections. J Orthop Trauma 2024; 38:247-253. [PMID: 38259060 DOI: 10.1097/bot.0000000000002775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 01/24/2024]
Abstract
OBJECTIVES To assess the relationship between patient smoking status and fracture-related infection (FRI) characteristics including patient symptoms at FRI presentation, bacterial species of FRI, and rates of fracture union. METHODS DESIGN Retrospective cohort study. SETTING Urban level 1 trauma center. PATIENT SELECTION CRITERIA All patients undergoing reoperation for FRI from January 2013 to April 2021 were identified through manual review of an institutional database. OUTCOME MEASURES AND COMPARISONS Data including patient demographics, fracture characteristics, infection presentation, and hospital course were collected through review of the electronic medical record. Patients were grouped based on current smoker versus nonsmoker status. Hospital course and postoperative outcomes of these groups were then compared. Risk factors of methicillin-resistant Staphylococcus aureus (MRSA) infection, Staphylococcus epidermidis infection, and sinus tract development were evaluated using multivariable logistic regression. RESULTS A total of 301 patients, comprising 155 smokers (51%) and 146 nonsmokers (49%), undergoing FRI reoperation were included. Compared with nonsmokers, smokers were more likely male (69% vs. 56%, P = 0.024), were younger at the time of FRI reoperation (41.7 vs. 49.5 years, P < 0.001), and had lower mean body mass index (27.2 vs. 32.0, P < 0.001). Smokers also had lower prevalence of diabetes mellitus (13% vs. 25%, P = 0.008) and had higher Charlson Comorbidity Index 10-year estimated survival (93% vs. 81%, P < 0.001). Smokers had a lower proportion of S. epidermidis infections (11% vs. 20%, P = 0.037), higher risk of nonunion after index fracture surgery (74% vs. 61%, P = 0.018), and higher risk of sinus tracts at FRI presentation (38% vs. 23%, P = 0.004). On multivariable analysis, smoking was not found to be associated with increased odds of MRSA infection. CONCLUSIONS Among patients who develop a FRI, smokers seemed to have better baseline health regarding age, body mass index, diabetes mellitus, and Charlson Comorbidity Index 10-year estimated survival compared with nonsmokers. Smoking status was not significantly associated with odds of MRSA infection. However, smoking status was associated with increased risk of sinus tract development and nonunion and lower rates of S. epidermidis infection at the time of FRI reoperation. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Evan G Gross
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Zuhair Mohammed
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Karen J Carter
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Elizabeth M Benson
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Gerald McGwin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Alexander Mihas
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Austin C Atkins
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Joey P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
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Abdulsamad AM, Al Mugren T, Alzahrani MT, Alanbar FT, Althunayan TA, Mahayni A, Alfarag AH, Alotaibi MT, Almuqbil M, Alfarraj AH. Outcomes of the Treatment of Humeral Shaft Fractures by Closed Reduction and Internal Fixation With Multiple Intramedullary Kirschner Wires (K-wires). Cureus 2023; 15:e51009. [PMID: 38143728 PMCID: PMC10748805 DOI: 10.7759/cureus.51009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 12/26/2023] Open
Abstract
Background Humeral shaft fractures are common orthopedic injuries, and their treatment options vary based on fracture characteristics. One surgical method involves closed reduction and internal fixation (CRIF) with multiple intramedullary (IM) Kirschner wires (K-wires), which remains less explored, especially in adults. This study aims to investigate the outcomes of the treatment of humeral shaft fractures by closed reduction and internal fixation with multiple flexible intramedullary K-wires. Materials and methods We conducted a retrospective study at King Abdulaziz Medical City, Riyadh, Saudi Arabia, focusing on patients with traumatic humeral shaft fractures who underwent flexible intramedullary K-wire fixation. We analyzed nine patient records for demographic information, fracture location, type, mechanism of injury, intra-operative and post-operative factors, and complications. Results Fractures mostly affected the middle third of the humerus (55.6%) and were primarily transverse or oblique (77.8%). Motor vehicle accidents were the leading cause of injury (66.7%). Intra-operative time was 125 minutes on average, with minimal blood loss (78 mL). No participants required intra-operative blood transfusion. Complications following IM K-wire fixation were absent in all cases. Three patients had not yet undergone instrumental removal, and most reported mild or no pain during the final follow-up. All participants achieved a full range of motion for their elbows. All participants achieved complete radiological and clinical union (healing) of their fractures. Conclusion The use of multiple intramedullary K-wires for the treatment of humeral shaft fractures in this study demonstrated positive outcomes with low complication rates. This approach provides an effective option for managing these fractures, particularly in cases where surgical indications favor it.
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Affiliation(s)
- Adham M Abdulsamad
- Department of Surgery, Division of Orthopedic Surgery, King Abdulaziz Medical City, Riyadh, SAU
| | - Turki Al Mugren
- Department of Surgery, Division of Orthopedic Surgery, King Abdulaziz Medical City, Riyadh, SAU
| | - Mohammed T Alzahrani
- Department of Surgery, Division of Orthopedic Surgery, King Abdulaziz Medical City, Riyadh, SAU
| | - Faisal T Alanbar
- Department of Surgery, Division of Orthopedic Surgery, King Abdulaziz Medical City, Riyadh, SAU
| | - Turki A Althunayan
- Department of Surgery, Division of Orthopedic Surgery, King Abdulaziz Medical City, Riyadh, SAU
| | - Abdullah Mahayni
- Department of Surgery, Division of Orthopedic Surgery, King Abdulaziz Medical City, Riyadh, SAU
| | - Abdulrahman H Alfarag
- Department of Surgery, Division of Orthopedic Surgery, King Abdulaziz Medical City, Riyadh, SAU
| | - Mohammad T Alotaibi
- Department of Orthopedic Surgery, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Musab Almuqbil
- Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Ahmed H Alfarraj
- Department of Orthopedic Surgery, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
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Freigang V, Walter N, Rupp M, Riedl M, Alt V, Baumann F. Treatment of Fracture-Related Infection after Pelvic Fracture. J Clin Med 2023; 12:6221. [PMID: 37834865 PMCID: PMC10573264 DOI: 10.3390/jcm12196221] [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: 08/08/2023] [Revised: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND The management of pelvic fractures is a significant challenge. Surgical site infection can result in the need for revision surgery, cause functional impairment, and lead to a prolonged length of stay and increased treatment costs. Although reports on fracture-related infection (FRI) after pelvic fracture fixation are sparsely reported in the literature, it is a serious complication. This study analysed patients with FRIs after pelvic fracture regarding patient characteristics, treatment strategies, and an evaluation of risk factors for FRI. METHODS In this retrospective single-centre study, FRI was diagnosed based on clinical symptoms of infection and a positive culture of a bacterial infection. Depending on the severity and acuteness of the infection, osseous stabilization was restored either via implant retention (stable implant, no osteolysis), exchange (loose implant or bony defect), or external fixation (recurrence of infection after prior implant retaining revision). Healing of infection was defined as no sign of recurring infection upon clinical, radiological, and laboratory examination in the last follow-up visit. RESULTS The FRI rate in our patient population was 7.5% (24/316). In 8/24 patients, the FRI occurred within the first three weeks after initial surgery (early) and 16/24 presented with a late onset of symptoms of FRI. A strategy of debridement, antibiotics, and implant retention (DAIR) was successful in 9/24 patients with FRI after pelvic fracture. A total of 10 patients required an exchange of osteo-synthetic implants, whereof three were exchanged to an external fixator. In five patients, we removed the implant because the fracture had already consolidated at the time of revision for infection. A total of 17/24 patients had a poly-microbial infection after a pelvic fracture and 3/24 patients died from post-traumatic multi-organ failure within the first 6 months after trauma. There were no cases of persistent infection within the remaining 21 patients. CONCLUSIONS Although poly-microbial infection is common in FRI after pelvic fracture, the recurrence rate of infection is relatively low. A complex pelvic trauma with significant soft tissue injury is a risk factor for recurrent infection and multiple revisions. A strategy of DAIR can be successful in patients with a stable implant. In cases with recurrent infection or an unstable fracture site, the exchange of implants should be considered.
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Affiliation(s)
- Viola Freigang
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
- Faculty of Interdisciplinary Studies, Landshut University of Applied Sciences, Am Lurzenhof 1, 84036 Landshut, Germany
| | - Nike Walter
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Moritz Riedl
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Florian Baumann
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
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Matsuno Y, Takegami Y, Tokutake K, Takami H, Kurokawa H, Iwata M, Terasawa S, Yamauchi KI, Imagama S. Incidence and Risk Factors for Fracture-Related Infection After Peri-Prosthetic Femoral Fractures: A Multicenter Retrospective Study (TRON Group Study). Surg Infect (Larchmt) 2023. [PMID: 37155200 DOI: 10.1089/sur.2022.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Background: Fracture-related infection (FRI) sometimes occurs with peri-prosthetic femoral fracture (PPF) treatment. Fracture-related infection often leads to multiple re-operations, possible non-union, a decreased clinical function, and long-term antibiotic treatment. In this multicenter study, we aimed to clarify the incidence of FRI, the causative organisms of wound infection, and the risk factors associated with post-operative infection for PPF. Patients and Methods: Among 197 patients diagnosed with peri-prosthetic femoral fracture who received surgical treatment in 11 institutions (named the TRON group) from 2010 to 2019, 163 patients were included as subjects. Thirty-four patients were excluded because of insufficient follow-up (less than six months) or data loss. We extracted the following risk factors for FRI: gender, body mass index, smoking history, diabetes mellitus, chronic hepatitis, rheumatoid arthritis, dialysis, history of osteoporosis treatment, injury mechanism (high- or low-energy), Vancouver type, and operative information (waiting period for surgery, operation time, amount of blood loss, and surgical procedure). We conducted a logistic regression analysis to investigate the risk factors for FRI using these extracted items as explanatory variables and the presence or absence of FRI as the response variable. Results: Fracture-related infection occurred after surgery for PPF in 12 of 163 patients (7.3%). The most common causative organism was Staphylococcus aureus (n = 7). The univariable analysis showed differences for dialysis (p = 0.001), Vancouver type (p = 0.036), blood loss during surgery (p = 0.001), and operative time (p = 0.001). The multivariable logistic-regression analysis revealed that the patient background factor of dialysis (odds ratio [OR], 22.9; p = 0.0005), and the operative factor of Vancouver type A fracture (OR, 0.039-1.18; p = 0.018-0.19) were risk factors for FRI. Conclusions: The rate of post-operative wound infection in patients with a PPF was 7.3%. Staphylococcus was the most frequent causative organism. The surgeon should pay attention to infection after surgery for patients with Vancouver type A fractures and those undergoing dialysis.
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Affiliation(s)
- Yuji Matsuno
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideomi Takami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Kurokawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Manato Iwata
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Terasawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ken-Ichi Yamauchi
- Department of Orthopedic Surgery, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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