Use of negative pressure wound therapy in patients with fracture-related infection more than doubles the risk of recurrence

[Treatment strategies for fracture-related infections with concurrent soft tissue damage]

Fracture-related infections are the predominant complication following surgical fracture treatment. The distal lower leg, e.g., in pilon tibial fractures, is at a high risk of infection due to poor soft tissue coverage, particularly in cases of open fractures in this area. Fracture-related infections with significant soft tissue damage require special attention alongside treatment of the infection itself. In general, the principle is that healing of fracture-related infection is not possible without sufficient soft tissue coverage. Therefore, it is crucial to integrate both soft tissue damage and fracture-related infection into a comprehensive treatment plan from the beginning. An interdiscpilinary treatment approach between trauma and plastic surgery is often necessary and beneficial. In cases, where fracture fixation devices or bone is exposed, mid- or long-term use of vacuum-assisted wound therapy is not advisable due to a higher risk of reinfection. Hence, an interdisciplinary treatment strategy involving trauma and plastic surgery should prioritize early soft tissue closure, referred to as the "orthoplastic approach". If this cannot be done in the own hospital, early patient transfer is indicated to ensure optimal interdisciplinary therapy with early soft tissue closure and simultaneous trauma surgical treatment to control the infection and enable bone healing. Free fasciocutaneous or muscle flap techniques in combination with adequate trauma surgical and antibiotic therapy lead to good reliable results in these situations.

Fracture-Related Infection-Epidemiology, Etiology, Diagnosis, Prevention, and Treatment

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.

Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group

A judicious, well-planned bone and soft tissue debridement remains one of the cornerstones of state-of-the-art treatment of fracture-related infection (FRI). Meticulous surgical excision of all non-viable tissue can, however, lead to the creation of large soft tissue defects. The management of these defects is complex and numerous factors need to be considered when selecting the most appropriate approach. This narrative review summarizes the current evidence with respect to soft tissue management in patients diagnosed with FRI. Specifically we discuss the optimal timing for tissue closure following debridement in cases of FRI, the need for negative microbiological culture results from the surgical site as a prerequisite for definitive wound closure, the optimal type of flap in case of large soft tissue defects caused by FRI and the role of negative pressure wound therapy (NPWT) in FRI. Finally, recommendations are made with regard to soft tissue management in FRI that should be useful for clinicians in daily clinical practice.Level of evidence Level V.

Vacuum sealing drainage combined with eggshell-like debridement antibiotic-loaded calcium sulphate for calcaneal osteomyelitis

BACKGROUND

To compare the clinical efficacy of vacuum sealing drainage, eggshell-like debridement combined with antibiotic calcium sulphate implantation and conventional debridement combined with antibiotic calcium sulphate implantation in the treatment of calcaneal osteomyelitis.

METHODS

Sixty-six patients with calcaneal osteomyelitis who were treated in our department between January 2017 and August 2021 were included in this study. Thirty-one patients underwent VSD and eggshell-like debridement combined with antibiotic calcium sulphate implantation. Thirty-five patients underwent conventional debridement combined with antibiotic calcium sulphate implantation. The inflammatory markers, operation time, wound healing time, hospital stay, full weight bearing time after operation, recurrence rate of infection, complications, and American Orthopedic Foot and Ankle Society (AOFAS) scores were compared between the two groups.

RESULTS

The operation time and full weight bearing time after operation of observation group were longer than that of control group. Compared with preoperative results, WBC, ESR, CRP and PCT in both groups were significantly decreased at 14 days after operation, and there was no statistical significance between the two groups. The wound healing time and hospital stay in the observation group were shorter than those in the control group (P < 0.05). There were four patients with aseptic exudation in the observation group and ten patients with aseptic exudation in the control group, and the wounds healed well after multiple dressing changes. Seven patients in the observation group underwent secondary bone grafting due to bone defects, and four patients in the control group received secondary bone grafting due to bone defects. In the observation group, three patients received debridement combined with antibiotic calcium sulphate implantation again due to recurrent infection, compared with seven patients in the control group. One year after operation, the observation group had a better AOFAS scores than the control group, especially in terms of foot function (P < 0.05).

CONCLUSION

Compared with conventional debridement and antibiotic calcium sulphate implantation, VSD and eggshell-like debridement combined with antibiotic calcium sulphate implantation in the treatment of calcaneal osteomyelitis can shorten the wound healing and hospital stay of patients, reduce postoperative aseptic exudation complications and infection recurrence rate, and better preserve the foot function, which is a simple and effective method.

The antibiotic bead pouch - a useful technique for temporary soft tissue coverage, infection prevention and therapy in trauma surgery

Soft tissue defects resulting from trauma and musculoskeletal infections can complicate surgical treatment. Appropriate temporary coverage of these defects is essential to achieve the best outcomes for necessary plastic soft tissue defect reconstruction. The antibiotic bead pouch technique is a reasonable surgical approach for managing temporary soft tissue defects following adequate surgical debridement. This technique involves the use of small diameter antibiotic-loaded bone cement beads to fill the dead space created by debridement. By applying antibiotics to the bone cement and covering the beads with an artificial skin graft, high local dosages of antibiotics can be achieved, resulting in the creation of a sterile wound that offers the best starting position for soft tissue and bone defect reconstruction. This narrative review describes the rationale for using this technique, including its advantages and disadvantages, as well as pearls and pitfalls associated with its use in daily practice. In addition, the article provides a comprehensive overview of the literature that has been published since the technique was introduced in surgical practice.

Current Concepts of Fracture-Related Infection

Currently, fracture-related infection (FRI) still represents great challenges in front of orthopaedic surgeons, despite great advances that have been achieved regarding its diagnosis and treatment. Although both FRI and prosthetic joint infection (PJI) belong to osteoarticular infections and share similarities, FRI displays unique characteristics. Diagnosis of FRI is sometimes difficult owing to the nonspecific symptoms, and treatment is usually tricky, with a high risk of infection recurrence. In addition, the long disease course is associated with a significantly elevated risk of disability, both physically and psychologically. Moreover, such a disorder still poses heavy economic burdens to the patients, both personally and socially. Therefore, early diagnosis and reasonable treatment are the key issues for increasing the cure rate, decreasing the risks of infection relapse and disability, and improving the life quality and prognosis of the patients. In this review, we summarized the present concepts regarding the definition, epidemiology, diagnosis, and treatment of FRI.