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Trenkwalder K, Hackl S, Weisemann F, Augat P. The value of current diagnostic techniques in the diagnosis of fracture-related infections: Serum markers, histology, and cultures. Injury 2024:111862. [PMID: 39277525 DOI: 10.1016/j.injury.2024.111862] [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: 02/15/2024] [Revised: 09/02/2024] [Accepted: 09/03/2024] [Indexed: 09/17/2024]
Abstract
Although fracture-related infection (FRI) is a serious complication following bone fractures, a comprehensive definition and diagnostic criteria have only emerged in recent years. According to this consensus definition, the diagnosis of FRI is based on preoperative and intraoperative suggestive or confirmatory criteria. Serum markers, histology, and microbiological cultures are considered to play a crucial role in the FRI diagnostic pathway. However, at the time of publication of the FRI consensus definition in 2018 and its update in 2020, limited data was available on the accuracy of these diagnostic methods. This review aims to provide an overview of recent publications and discuss whether new evidence has been obtained regarding the value of these current diagnostic techniques. Meanwhile, several studies have confirmed the limited prognostic value of C-reactive protein, erythrocyte sedimentation ratio, and white blood cell count. Other serologic markers for preoperative diagnosis of FRI with promising diagnostic performance are d-dimer, plasma fibrinogen, platelet count to mean platelet volume ratio, and a risk prediction model that includes soft tissue injury type and fracture complexity in addition to blood markers. However, their true diagnostic value in daily clinical practice needs to be investigated in further studies. Data on histology in FRI diagnosis is still limited, but its potential as a confirmatory criterion seems to lie in its high specificity. Recent studies indicate that tissue culture exhibits moderate sensitivity and high specificity, with sensitivity improvements achieved by sampling of five specimens and long-term culture. Implant sonication also appears to enhance the sensitivity of culture and the detection rate of polymicrobial infections. In conclusion, the true value of diagnostic techniques is difficult to assess, in part because it is measured against a gold standard that is itself imperfect and still evolving, but also because of methodological differences in sample processing or the use of different thresholds. Nevertheless, this review has identified that the value of current diagnostic techniques is high when used in combination. To draw more accurate conclusions about the value of serum markers, histology, and culture including sonication, future studies should be prospective and utilize a greater standardization in sampling and methodological protocols.
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Affiliation(s)
- Katharina Trenkwalder
- Institute for Biomechanics, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418 Murnau am Staffelsee, Germany; Institute for Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria.
| | - Simon Hackl
- Institute for Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria; Department of Trauma Surgery, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418 Murnau am Staffelsee, Germany
| | - Ferdinand Weisemann
- Department of Trauma Surgery, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418 Murnau am Staffelsee, Germany
| | - Peter Augat
- Institute for Biomechanics, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418 Murnau am Staffelsee, Germany; Institute for Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
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2
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Tay HW, Tay KS. Future directions for early detection of fracture related infections. J Orthop 2024; 55:64-68. [PMID: 38655538 PMCID: PMC11035015 DOI: 10.1016/j.jor.2024.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction Fracture related infection (FRI) refers to pathogens infecting a fracture site and hence impeding fracture healing. It is a significant complication that carries substantial disease burden and socio-economic costs, but has had limited scientific development. Hence, this paper will review the existing strategies for early detection of FRI, in the form of serum markers, molecular diagnostics and imaging modalities, and further discuss potential future directions for improved detection of FRI. Existing Strategies for Diagnosis of FRI The Anti-infection Global Expert Committee (AIGEC) developed a consensus definition for FRI in 2017, which includes confirmatory and suggestive criteria for diagnosis of FRI. Existing strategies for diagnosis include clinical, laboratory, histopathological, microbiological and radiological investigations. Future Directions for Early Detection of FRI With increasing recognition of FRI, early detection is crucial for early treatment to be enforced. We have identified potential areas for future development in diagnostics for early detection of FRI, which are discussed in this manuscript. They include inflammatory cytokines, serum calcium levels, platelet count, improved management of histopathological and microbiological specimens, metagenomics, wound biomarkers, gut microbiota analysis, and novel imaging technologies.
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Affiliation(s)
- Hui Wen Tay
- Singapore General Hospital Department of Orthopaedic Surgery, Singapore
| | - Kae Sian Tay
- Singapore General Hospital Department of Orthopaedic Surgery, Singapore
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3
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Ancuța DL, Lovati AB, Coman C. The clinical significance of inflammatory biomarkers, IL6 cytokine, and systemic immune inflammatory index in rabbit model of acute and chronic Methicillin-resistant Staphylococcus epidermidis-induced osteomyelitis. PLoS One 2024; 19:e0309145. [PMID: 39208074 PMCID: PMC11361425 DOI: 10.1371/journal.pone.0309145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 08/06/2024] [Indexed: 09/04/2024] Open
Abstract
Infections are a major complication of open fractures and fracture fixation. In this study, an innovative bioactive medical device was used to experimentally treat MRSE-induced osteomyelitis in rabbit tibia. This paper investigates the clinical significance of inflammatory biomarkers (NLR, PLR, MLR and PMR), SII and IL-6 and assesses their role in the development of osteomyelitis. The main objective is to identify the utility of hematological reports derived from neutrophils, leukocytes, monocytes and platelets in the evolution of implant-related osteomyelitis and the estimation of treatment efficiency. In particular, this study compares the response of these inflammatory markers to different treatments in the presence or absence of bioactive materials and/or topical antibiotics over time. The analysis of the threads showed that NLR, PLR and SII had high values in the acute phase of the disease, so that after chronicization, they decrease. The animals treated with vancomycin nano-functionalized peptide-enriched silk fibroin-coated implants showed lower levels of inflammatory biomarkers compared to the other groups (empty implants and peptide-enriched silk fibroin-coated implants). NLR, PLR and SII, complemented by IL-6 can be used as fairly accurate biomarkers for the diagnosis of osteomyelitis.
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Affiliation(s)
- Diana-Larisa Ancuța
- Cantacuzino National Medical Military Institute for Research and Development, Bucharest, Romania
| | | | - Cristin Coman
- Cantacuzino National Medical Military Institute for Research and Development, Bucharest, Romania
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4
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Siverino C, Metsemakers WJ, Sutter R, Della Bella E, Morgenstern M, Barcik J, Ernst M, D'Este M, Joeris A, Chittò M, Schwarzenberg P, Stoddart M, Vanvelk N, Richards G, Wehrle E, Weisemann F, Zeiter S, Zalavras C, Varga P, Moriarty TF. Clinical management and innovation in fracture non-union. Expert Opin Biol Ther 2024:1-19. [PMID: 39126182 DOI: 10.1080/14712598.2024.2391491] [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: 05/21/2024] [Revised: 07/18/2024] [Accepted: 08/08/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION With the introduction and continuous improvement in operative fracture fixation, even the most severe bone fractures can be treated with a high rate of successful healing. However, healing complications can occur and when healing fails over prolonged time, the outcome is termed a fracture non-union. Non-union is generally believed to develop due to inadequate fixation, underlying host-related factors, or infection. Despite the advancements in fracture fixation and infection management, there is still a clear need for earlier diagnosis, improved prediction of healing outcomes and innovation in the treatment of non-union. AREAS COVERED This review provides a detailed description of non-union from a clinical perspective, including the state of the art in diagnosis, treatment, and currently available biomaterials and orthobiologics.Subsequently, recent translational development from the biological, mechanical, and infection research fields are presented, including the latest in smart implants, osteoinductive materials, and in silico modeling. EXPERT OPINION The first challenge for future innovations is to refine and to identify new clinical factors for the proper definition, diagnosis, and treatment of non-union. However, integration of in vitro, in vivo, and in silico research will enable a comprehensive understanding of non-union causes and correlations, leading to the development of more effective treatments.
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Affiliation(s)
- C Siverino
- AO Research Institute Davos, Davos Platz, Switzerland
| | - W-J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
| | - R Sutter
- Radiology Department, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - E Della Bella
- AO Research Institute Davos, Davos Platz, Switzerland
| | - M Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - J Barcik
- AO Research Institute Davos, Davos Platz, Switzerland
| | - M Ernst
- AO Research Institute Davos, Davos Platz, Switzerland
| | - M D'Este
- AO Research Institute Davos, Davos Platz, Switzerland
| | - A Joeris
- AO Innovation Translation Center, Davos Platz, Switzerland
| | - M Chittò
- AO Research Institute Davos, Davos Platz, Switzerland
| | | | - M Stoddart
- AO Research Institute Davos, Davos Platz, Switzerland
| | - N Vanvelk
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - G Richards
- AO Research Institute Davos, Davos Platz, Switzerland
| | - E Wehrle
- AO Research Institute Davos, Davos Platz, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - F Weisemann
- Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau am Staffelsee, Germany
| | - S Zeiter
- AO Research Institute Davos, Davos Platz, Switzerland
| | - C Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - P Varga
- AO Research Institute Davos, Davos Platz, Switzerland
| | - T F Moriarty
- AO Research Institute Davos, Davos Platz, Switzerland
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
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Natoli RM, Malek S. Fracture-related infection blood-based biomarkers: Diagnostic strategies. Injury 2024:111823. [PMID: 39164161 DOI: 10.1016/j.injury.2024.111823] [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: 03/06/2024] [Revised: 06/30/2024] [Accepted: 08/10/2024] [Indexed: 08/22/2024]
Abstract
Fracture-related infections are significant postoperative complications that carry substantial patient burden and additional healthcare costs. Despite their impact on outcome, early diagnosis of these infections remains challenging due to current available tests lacking acceptable diagnostic parameters. This review compiles existing information on blood-based biomarkers that have been evaluated as early diagnostic tools and highlights the challenges in their reliability. To begin to overcome these challenges new avenues of biomarker discovery utilizing "omics" technologies and novel analytical methods are being investigated in recent years. It appears that, despite their complexity, these newer approaches may be the future in biomarker discovery for fracture-related infection diagnosis.
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Affiliation(s)
- Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Sarah Malek
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, IN, USA
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Ansert EA, Tarricone AN, Coye TL, Crisologo PA, Truong D, Suludere MA, Lavery LA. Update of biomarkers to diagnose diabetic foot osteomyelitis: A meta-analysis and systematic review. Wound Repair Regen 2024; 32:366-376. [PMID: 38566503 DOI: 10.1111/wrr.13174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/14/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024]
Abstract
The aim of this study was to evaluate the diagnostic characteristics of biomarker for diabetic foot osteomyelitis (DFO). We searched PubMed, Scopus, Embase and Medline for studies who report serological markers and DFO before December 2022. Studies must include at least one of the following diagnostic parameters for biomarkers: area under the curve, sensitivities, specificities, positive predictive value, negative predictive value. Two authors evaluated quality using the Quality Assessment of Diagnostic Accuracy Studies tool. We included 19 papers. In this systematic review, there were 2854 subjects with 2134 (74.8%) of those patients being included in the meta-analysis. The most common biomarkers were erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and procalcitonin (PCT). A meta-analysis was then performed where data were evaluated with Forrest plots and receiver operating characteristic curves. The pooled sensitivity and specificity were 0.72 and 0.75 for PCT, 0.72 and 0.76 for CRP and 0.70 and 0.77 for ESR. Pooled area under the curves for ESR, CRP and PCT were 0.83, 0.77 and 0.71, respectfully. Average diagnostic odds ratios were 16.1 (range 3.6-55.4), 14.3 (range 2.7-48.7) and 6.7 (range 3.6-10.4) for ESR, CRP and PCT, respectfully. None of the biomarkers we evaluated could be rated as 'outstanding' to diagnose osteomyelitis. Based on the areas under the curve, ESR is an 'excellent' biomarker to detect osteomyelitis, and CRP and PCT are 'acceptable' biomarkers to diagnose osteomyelitis. Diagnostic odds ratios indicate that ESR, CRP and PCT are 'good' or 'very good' tools to identify osteomyelitis.
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Affiliation(s)
- Elizabeth A Ansert
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Arthur N Tarricone
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Orthopedic Surgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Tyler L Coye
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Peter A Crisologo
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - David Truong
- Surgical Service, Podiatry Section, Veteran Affairs North Texas Health Care System, Dallas, Texas, USA
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mehmet A Suludere
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Coelho A, Alier A, Martínez-Diaz S, Puig-Verdié L, Gómez-Junyent J, García-Bernedo C, Pérez-Prieto D. High Rate of Undetected Infections in Failed Osteosynthesis of Pertrochanteric Fractures. J Orthop Trauma 2024; 38:327-332. [PMID: 38466816 DOI: 10.1097/bot.0000000000002801] [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: 03/06/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE The objective of this study was to assess the incidence of infection in patients with cutout after proximal femur fracture (PFF) osteosynthesis. METHODS DESIGN Retrospective cohort study. SETTING Third-level trauma center. PATIENT SELECTION CRITERIA Patients presenting with a cutout following PFF (OTA/AO 31A) osteosynthesis, between January 2007 and December 2020. OUTCOME MEASUREMENTS AND COMPARISONS The primary outcome was infection according to the European Bone and Joint Infection Society criteria. RESULTS Sixty-seven patients presenting with a cutout were included, with mean age of 83.3 years (range 63-96), and 51 (76.1%) were women. Of all cases, 16 (24.7%) presented a concomitant infection. The presence of concomitant infection was suspected preoperatively in only 3 of the cases. A subgroup analysis was performed between the cases with infection and those without infection, the groups being comparable in terms of demographic data and postoperative radiological criteria. Patients with underlying infection had a higher rate of surgical wound complication (56.3% vs. 22%, P = 0.014) and higher rates of leukocytosis (11.560 vs. 7.890, P = 0.023). CONCLUSION Faced with a cutout after osteosynthesis of a PFF, underlying infection should be considered as a possible etiological factor. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexandre Coelho
- Department of Orthopaedics, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Albert Alier
- Department of Orthopaedics, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Santos Martínez-Diaz
- Department of Orthopaedics, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Lluis Puig-Verdié
- Department of Orthopaedics, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Joan Gómez-Junyent
- Department of Infectious Diseases, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain; and
| | - Carlos García-Bernedo
- Department of Anesthesiology, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Daniel Pérez-Prieto
- Department of Orthopaedics, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
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Becker K, Sharma I, Slaven JE, Mosley AL, Doud EH, Malek S, Natoli RM. Proteomic Analyses of Plasma From Patients With Fracture-Related Infection Reveals Systemic Activation of the Complement and Coagulation Cascades. J Orthop Trauma 2024; 38:e111-e119. [PMID: 38117580 PMCID: PMC10922838 DOI: 10.1097/bot.0000000000002752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVES The objective of this study was to compare plasma proteomes of patients with confirmed fracture-related infections (FRIs) matched to noninfected controls using liquid chromatography-mass spectrometry. METHODS DESIGN This was a prospective case-control study. SETTING The study was conducted at a single, academic, Level 1 trauma center. PATIENT SELECTION CRITERIA Patients meeting confirmatory FRI criteria were matched to controls without infection based on fracture region, age, and time after surgery from June 2019 to January 2022. Tandem mass tag liquid chromatography-mass spectrometry analysis of patient plasma samples was performed. OUTCOME MEASURES AND COMPARISONS Protein abundance ratios in plasma for patients with FRI compared with those for matched controls without infection were calculated. RESULTS Twenty-seven patients meeting confirmatory FRI criteria were matched to 27 controls. Abundance ratios for more than 1000 proteins were measured in the 54 plasma samples. Seventy-three proteins were found to be increased or decreased in patients with FRI compared with those in matched controls (unadjusted t test P < 0.05). Thirty-two of these proteins were found in all 54 patient samples and underwent subsequent principal component analysis to reduce the dimensionality of the large proteomics dataset. A 3-component principal component analysis accounted for 45.7% of the variation in the dataset and had 88.9% specificity for the diagnosis of FRI. STRING protein-protein interaction network analysis of these 3 PCs revealed activation of the complement and coagulation cascades through the Reactome pathway database (false discovery rates <0.05). CONCLUSIONS Proteomic analyses of plasma from patients with FRI demonstrate systemic activation of the complement and coagulation cascades. Further investigation along these lines may help to better understand the systemic response to FRI and improve diagnostic strategies using proteomics. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kevin Becker
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Ishani Sharma
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - James E Slaven
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - Amber L Mosley
- Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN
- Center for Proteome Analysis, Indiana University School of Medicine, Indianapolis, IN; and
| | - Emma H Doud
- Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN
- Center for Proteome Analysis, Indiana University School of Medicine, Indianapolis, IN; and
| | - Sarah Malek
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, IN
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
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Dai Y, Yi X, Huang Y, Qian K, Huang L, Hu J, Liu Y. miR-345-3p Modulates M1/M2 Macrophage Polarization to Inhibit Inflammation in Bone Infection via Targeting MAP3K1 and NF-κB Pathway. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2024; 212:844-854. [PMID: 38231123 DOI: 10.4049/jimmunol.2300561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Abstract
Infection after fracture fixation (IAFF), a complex infectious disease, causes inflammatory destruction of bone tissue and poses a significant clinical challenge. miR-345-3p is a biomarker for tibial infected nonunion; however, the comprehensive mechanistic role of miR-345-3p in IAFF is elusive. In this study, we investigated the role of miR-345-3p in IAFF pathogenesis through in vivo and in vitro experiments. In vivo, in a rat model of IAFF, miR-345-3p expression was downregulated, accompanied by increased M1 macrophage infiltration and secretion of proinflammatory factors. In vitro, LPS induced differentiation of primary rat bone marrow-derived macrophages into M1 macrophages, which was attenuated by miR-345-3p mimics. miR-345-3p promoted M1 to M2 macrophage transition-it reduced the expression of cluster of differentiation (CD) 86, inducible NO synthase, IL-1β, and TNF-α but elevated those of CD163, arginase-1, IL-4, and IL-10. MAPK kinase kinase 1 (MAP3K1), a target mRNA of miR-345-3p, was overexpressed in the bone tissue of IAFF rats compared with that in those of the control rats. The M1 to M2 polarization inhibited MAP3K1 signaling pathways in vitro. Conversely, MAP3K1 overexpression promoted the transition from M2 to M1. miR-345-3p significantly inhibited NF-κB translocation from the cytosol to the nucleus in a MAP3K1-dependent manner. In conclusion, miR-345-3p promotes the polarization of M1 macrophages to the M2 phenotype by inhibiting the MAP3K1 and NF-κB pathways. These findings provide insight into the pathogenesis and immunotherapeutic strategies for IAFF and offer potential new targets for subsequent research.
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Affiliation(s)
- Yan Dai
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaolan Yi
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yahui Huang
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kaoliang Qian
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lili Huang
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jun Hu
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuan Liu
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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10
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Wang Z, Mao H, Xu G. Fibrinogen, albumin-to-globulin ratio, and fibrinogen to albumin-to-globulin ratio may be potential diagnostic biomarkers for infected tibial nonunion. Int Immunopharmacol 2023; 121:110542. [PMID: 37356122 DOI: 10.1016/j.intimp.2023.110542] [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: 04/05/2023] [Revised: 06/02/2023] [Accepted: 06/17/2023] [Indexed: 06/27/2023]
Abstract
AIM The accurate preoperative diagnosis of infected tibial nonunion remains challenging. Hence, we evaluated the diagnostic potential of novel biomarkers for infected tibial nonunion. METHODS This single-center retrospective study was conducted in 252 patients divided into two groups: infected tibial nonunion (67 patients) and aseptic tibial nonunion (185 patients). The preoperative clinical biomarkers included D-dimer, fibrinogen, albumin, globulin, total protein, and C-reactive protein (CRP) levels; albumin-to-globulin ratio (AGR); erythrocyte sedimentation rate (ESR); and white blood cell (WBC) count. Receiver operating characteristic (ROC) curves, sensitivity, and specificity were utilized to compare the biomarkers' diagnostic potential. RESULTS The area under the curve (AUC) values for fibrinogen and AGR were 0.829 and 0.821, respectively, suggesting similarly good diagnostic potentials for infected tibial nonunion. Fibrinogen and AGR were better diagnostic biomarkers for infected tibial nonunion than the WBC count; ESR; D-dimer, albumin, globulin, CRP, and total protein levels, whose AUC values were 0.623, 0.684, 0.741, 0.797, 0.765, 0.715, and 0.554, respectively. The sensitivity and specificity of fibrinogen with a cut-off value of 3.35 g/L were 71.64% and 84.86%, respectively. The corresponding values for AGR with a cut-off value of 1.33 were 73.13% and 86.49%. Moreover, the fibrinogen-AGR (FAGR), i.e., the combination of fibrinogen and AGR, had the highest diagnostic accuracy for infected tibial nonunion (AUC = 0.906). The optimal FAGR cut-off was 2.69, with fair sensitivity (74.63%) but the highest specificity (94.59%). CONCLUSION Fibrinogen, AGR, and FAGR are promising biomarkers for the diagnosis of infected tibial nonunion.
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Affiliation(s)
- Zhen Wang
- Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Haijun Mao
- Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Guangyue Xu
- Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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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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12
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He SY, Yu B, Jiang N. Current Concepts of Fracture-Related Infection. Int J Clin Pract 2023; 2023:4839701. [PMID: 37153693 PMCID: PMC10154639 DOI: 10.1155/2023/4839701] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/24/2023] [Accepted: 04/08/2023] [Indexed: 05/10/2023] Open
Abstract
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.
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Affiliation(s)
- Si-ying He
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
| | - Bin Yu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
| | - Nan Jiang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
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13
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Wang Z, Mao H, Xu G. Combination of albumin-to-globulin ratio and plasma fibrinogen is a sensitive tool for preoperative screening of infected nonunion in patients undergoing reoperation after open reduction and internal fixation: a retrospective study. J Orthop Surg Res 2022; 17:471. [PMID: 36309703 PMCID: PMC9618180 DOI: 10.1186/s13018-022-03363-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Accurate preoperative diagnosis of infected nonunion remains a challenge. Here, we evaluated the diagnostic potential of novel biomarkers for infected nonunion. Methods A cohort of 275 patients who underwent surgery for suspected septic nonunion after open reduction and internal fixation were enrolled. Preoperatively analyzed clinical parameters included white blood cell (WBC) count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), albumin, globulin, albumin-to-globulin ratio (AGR), plasma D-dimer, plasma fibrinogen, platelet count (PC), monocyte-lymphocyte ratio (MLR), neutrophil–lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR). Receiver operating characteristic (ROC) curves, sensitivity, and specificity were utilized to compare the diagnostic potential of those biomarkers. Results The WBC count and levels of CRP, ESR, NLR, MLR, PLR, PC, plasma D-dimer, plasma fibrinogen, and globulin in infected nonunion patients were significantly higher (p < 0.05) than those in aseptic patients. The albumin and AGR levels of the infected nonunion group were significantly lower (p < 0.05) than the aseptic group. The ROC curve analysis showed that the diagnostic accuracy of AGR and plasma fibrinogen was good. The combination of AGR with plasma fibrinogen had the highest area under the curve (AUC) (0.916). The sensitivity and specificity were 70.27% and 91.04% for AGR, and 67.57% and 84.08% for plasma fibrinogen, respectively. The combination of AGR with plasma fibrinogen showed a sensitivity of 86.49% and specificity of 92.54%. In patients with comorbidities, the diagnostic accuracy of the combination of AGR with plasma fibrinogen was also good. Conclusions AGR and plasma fibrinogen are promising biomarkers to improve the diagnosis of infected nonunion. The combination of AGR with plasma fibrinogen is a sensitive tool for screening infected nonunion.
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14
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Utility of Plasma Protein Biomarkers and Mid-infrared Spectroscopy for Diagnosing Fracture-related Infections: A Pilot Study. J Orthop Trauma 2022; 36:e380-e387. [PMID: 35452050 DOI: 10.1097/bot.0000000000002379] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare a large panel of plasma protein inflammatory biomarkers and mid-infrared (MIR) spectral patterns in patients with confirmed fracture-related infections (FRIs) with those in controls without infection. DESIGN Prospective case-control study. SETTING Academic, Level 1 trauma center. PATIENTS Thirteen patients meeting confirmatory FRI criteria were matched to 13 controls based on age, time after surgery, and fracture region. INTERVENTION Plasma levels of 49 proteins were measured using enzyme-linked immunosorbent assay techniques. Fourier transform infrared spectroscopy of dried films was used to obtain MIR spectra of plasma samples. MAIN OUTCOME MEASUREMENTS The main outcome measurements included plasma protein levels and MIR spectra of samples. RESULTS Multivariate analysis-based predictive model developed using enzyme-linked immunosorbent assay-based biomarkers had sensitivity, specificity, and accuracy of 69.2% ± 0.0%, 99.9% ± 1.0%, and 84.5% ± 0.6%, respectively, with platelet-derived growth factor-AB/BB, C-reactive protein, and MIG selected as the minimum number of variables explaining group differences ( P < 0.05). Sensitivity, specificity, and accuracy of the predictive model based on MIR spectra were 69.9% ± 6.2%, 71.9% ± 5.9%, and 70.9% ± 4.8%, respectively, with 6 wavenumbers as explanatory variables ( P < 0.05). CONCLUSIONS This pilot study demonstrates the feasibility of using a select panel of plasma proteins and Fourier transform infrared spectroscopy to diagnose FRIs. Preliminary data suggest that the measurement of these select proteins and MIR spectra may be potential clinical tools to detect FRIs. Further investigation of these biomarkers in a larger cohort of patients is warranted. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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15
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Shapiro JA, Stillwagon MR, Tornetta P, Seaver TM, Gage M, O’Donnell J, Whitlock K, Yarboro SR, Jeray KJ, Obremskey WT, Rodriguez-Buitrago A, Matuszewski P, Lin FC, Ostrum RF. Serology and Comorbidities in Patients With Fracture Nonunion: A Multicenter Evaluation of 640 Patients. J Am Acad Orthop Surg 2022; 30:e1179-e1187. [PMID: 36166389 PMCID: PMC9521813 DOI: 10.5435/jaaos-d-21-00366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/20/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion. METHODS From January 1, 2011, to December 31, 2017, consecutive individuals surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed. RESULTS A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time. DISCUSSION Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.
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Affiliation(s)
| | | | | | | | - Mark Gage
- Duke University Department of Orthopaedic Surgery
| | | | | | | | - Kyle J. Jeray
- Greenville Health System Department of Orthopaedic Surgery
| | | | | | - Paul Matuszewski
- University of Kentucky Department of Orthopaedic Surgery and Sports Medicine
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16
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Retrospective Analysis of Infection Factors in Secondary Internal Fixation after External Fixation for Open Fracture of a Long Bone: A Cohort of 117 Patients in a Two-Center Clinical Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7284068. [PMID: 35813227 PMCID: PMC9262577 DOI: 10.1155/2022/7284068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/10/2022] [Indexed: 11/18/2022]
Abstract
Purpose To investigate infection risk factors after secondary internal fixation (IF) of open fracture of a long bone with removed fixation frame and explore the safe range of feasible operation for abnormal inflammatory indicators. Methods Clinical data of 117 cases of open fracture of a long bone that underwent temporary external fixation (EF) in one stage and IF in two stages were retrospectively analyzed. Collected data included age, sex, Gustilo type, multiple injuries, debridement time, duration of EF, needle infection, interval of conversion to IF after external fixator, preoperative white blood cell (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin (ALB), blood glucose, and prognosis. We selected these factors for univariate analysis of postoperative surgical site infection (SSI) and multivariate logistic regression analysis of statistically significant risk factors and created receiver operating characteristic (ROC) curves to compare the diagnostic efficiency of each index and determine the optimal screening point. Results We followed up 117 patients, with 130 limbs affected. Univariate analysis showed that ESR, CRP, ALB, WBC, EF time, and Gustilo fracture type were significantly associated with SSI. Multivariate logistic regression analysis showed that CRP, duration of EF, and Gustilo fracture type were independently associated with postoperative infection. Area under ROC curves for WBC, ESR, and CRP were 69.7%, 73.2%, and 81.2%. Conclusions We demonstrated the role of Gustilo classification of open fractures in predicting postoperative infection, especially for open fractures above type III. If the inflammatory indexes return to normal or show a downward trend, and the second-stage IF operation is performed within the cutoff values, postoperative recurrent infection was reduced.
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17
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Diagnostic Value of the Blood Neutrophil-to-Lymphocyte Ratio and Monocyte-to-Lymphocyte Ratio in Tibia Fracture-Related Infection. DISEASE MARKERS 2022; 2022:6119583. [PMID: 35692886 PMCID: PMC9184170 DOI: 10.1155/2022/6119583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/16/2022] [Indexed: 12/25/2022]
Abstract
Objective. The diagnostic value of neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) in predicting fracture-related infection (FRI) in tibia fracture patients remains to be explored. Methods. A retrospective controlled study was carried out with 170 tibia FRI patients and 162 control subjects. The following information was evaluated at admission: age, gender, clinical features, number of white blood cells (WBCs), neutrophils, lymphocytes, monocytes, red blood cells (RBCs), platelets, level of hemoglobin, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR), as well as NLR, MLR, and PLR. Results. The number of lymphocytes, RBCs, and platelets in the FRI group was higher than those in the control group, while the number of neutrophils and ESR level was lower (
). The level of NLR and MLR was significantly lower in patients with tibia FRI than in control subjects (
). Both indicators were positively correlated with WBCs, CRP level, and ESR level (
). The results of logistic regression analysis showed that five variables including NLR, MLR, platelets, fracture pattern (closed or open fracture), and site pattern (single or multiple site) were used to construct the FRI risk predictor. The ROC curve analysis result showed that FRI risk predictor yielded the highest AUC, with a sensitivity of 91.2% and a specificity of 90.1%, and made the distinction efficiently between tibia FRI patients and non-FRI patients. Conclusion. NLR and MLR were decreased in tibia FRI patients compared to non-FRI patients. Both indicators had a positive correlation with WBCs, CRP level, and ESR level. FRI risk predictor constructed based on five variables including NLR and MLR had a high diagnostic value for tibia FRI.
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18
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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: 29] [Impact Index Per Article: 14.5] [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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19
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Lu V, Zhang J, Patel R, Zhou AK, Thahir A, Krkovic M. Fracture Related Infections and Their Risk Factors for Treatment Failure—A Major Trauma Centre Perspective. Diagnostics (Basel) 2022; 12:diagnostics12051289. [PMID: 35626444 PMCID: PMC9141112 DOI: 10.3390/diagnostics12051289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 12/25/2022] Open
Abstract
Fracture related infections (FRI) are debilitating and costly complications of musculoskeletal trauma surgery that can result in permanent functional loss or amputation. Surgical treatment can be unsuccessful, and it is necessary to determine the predictive variables associated with FRI treatment failure, allowing one to optimise them prior to treatment and identify patients at higher risk. The clinical database at a major trauma centre was retrospectively reviewed between January 2015 and January 2021. FRI treatment failure was defined by infection recurrence or amputation. A univariable logistic regression analysis was performed, followed by a multivariable regression analysis for significant outcomes between groups on univariable analysis, to determine risk factors for treatment failure. In total, 102 patients were identified with a FRI (35 open, 67 closed fractures). FRI treatment failure occurred in 24 patients (23.5%). Risk factors determined by our multivariate logistic regression model were obesity (OR 2.522; 95% CI, 0.259–4.816; p = 0.006), Gustilo Anderson type 3c (OR 4.683; 95% CI, 2.037–9.784; p = 0.004), and implant retention (OR 2.818; 95% CI, 1.588–7.928; p = 0.041). Given that FRI treatment in 24 patients (23.5%) ended up in failure, future management need to take into account the predictive variables analysed in this study, redirect efforts to improve management and incorporate adjuvant technologies for patients at higher risk of failure, and implement a multidisciplinary team approach to optimise risk factors such as diabetes and obesity.
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Affiliation(s)
- Victor Lu
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK; (J.Z.); (A.K.Z.)
- Correspondence:
| | - James Zhang
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK; (J.Z.); (A.K.Z.)
| | - Ravi Patel
- Hull York Medical School, University Rd, Heslington, York YO10 5DD, UK;
| | - Andrew Kailin Zhou
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK; (J.Z.); (A.K.Z.)
| | - Azeem Thahir
- Addenbrookes Hospital, Hills Rd, Cambridge CB2 0QQ, UK; (A.T.); (M.K.)
| | - Matija Krkovic
- Addenbrookes Hospital, Hills Rd, Cambridge CB2 0QQ, UK; (A.T.); (M.K.)
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20
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Png ME, Petrou S, Knight R, Masters J, Achten J, Costa ML. Economic outcomes associated with deep surgical site infection from lower limb fractures following major trauma. Bone Jt Open 2022; 3:398-403. [PMID: 35535505 PMCID: PMC9134829 DOI: 10.1302/2633-1462.35.bjo-2022-0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIMS This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma. METHODS Data from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses. RESULTS Compared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed. CONCLUSION This study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature. Cite this article: Bone Jt Open 2022;3(5):398-403.
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Affiliation(s)
- May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ruth Knight
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - James Masters
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
| | - Juul Achten
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
| | - Matthew L. Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
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Zhao X, Tang W, Wan H, Lan Z, Qin H, Lin Q, Hu Y, Yu G, Jiang N, Yu B. Altered Gut Microbiota as an Auxiliary Diagnostic Indicator for Patients With Fracture-Related Infection. Front Microbiol 2022; 13:723791. [PMID: 35495685 PMCID: PMC9048737 DOI: 10.3389/fmicb.2022.723791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 02/16/2022] [Indexed: 12/02/2022] Open
Abstract
Preoperative diagnosis of fracture-related infection (FRI) is difficult for patients without obvious signs of infection. However, specific profiles of gut microbiota may be used as a potential diagnostic tool for FRI as suggested by a previous study. The fecal microbiome was compared between 20 FRI patients (FRI group), 18 fracture healed patients (FH group), and 12 healthy controls (HC group) included after collection of fecal samples and evaluation. The α and β diversity indices were used to characterize the fecal microbiome. Dysbiosis indexes were constructed based on the characteristic high-dimensional biomarkers identified in the fecal microbiota from the three groups by linear discriminant analysis and generalized linear model analysis to quantify the dysbiosis of fecal microbiota. The effectiveness of α and β diversity indices and dysbiosis indexes was assessed in distinguishing the fecal microbiome among the three groups. The influences of serum inflammatory factors on gut microbiota were also addressed. The α diversity indices were significantly different between the three groups, the highest in HC group and the lowest in FRI group (P < 0.05). The β diversity indices showed significant phylogenetic dissimilarity of gut microbiome composition among the three groups (P < 0.001). The dysbiosis indexes were significantly higher in FRI group than in FH and HC groups (P < 0.001). The area under Receiver operating characteristic curve showed the characteristics of gut microbiota and the gut microbiota was found as effective in distinguishing the three groups. The dysbiosis in the FRI patients was associated with systemic inflammatory factors. In addition, significant differences in the gut microbiota were not observed between the FRI patients versus without sinus tract or pus before operation. Since FRI patients, with or without sinus tract or pus, have a characteristic profile of gut microbiota, their gut microbiota may be used as an auxiliary diagnostic tool for suspected FRI.
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Affiliation(s)
- Xingqi Zhao
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenli Tang
- Department of Bioinformatics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Haoyang Wan
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zixin Lan
- The Second Clinical Medical College, Southern Medical University, Guangzhou, China
| | - Hanjun Qin
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qingrong Lin
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanjun Hu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guangchuang Yu
- Department of Bioinformatics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- *Correspondence: Guangchuang Yu,
| | - Nan Jiang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Nan Jiang,
| | - Bin Yu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Bin Yu,
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Wang Z, Mao HJ, Qiu XS, Chen YX, Xu GY. Diagnostic value of platelet indices in infected nonunion: a retrospective study. J Orthop Surg Res 2022; 17:200. [PMID: 35379285 PMCID: PMC8981626 DOI: 10.1186/s13018-022-03096-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The diagnostic value of platelet indices has been evaluated in various infectious diseases but not in infected nonunion. The purpose of this study was to assess the usefulness of platelet indices for diagnosis of infected nonunion after open reduction and internal fixation. METHODS This retrospective study was performed in patients who underwent primary fracture nonunion revision surgeries from January 2016 to December 2021. A total of 297 patients were included in the study: 96 with infected nonunion (group A) and 201 with aseptic nonunion (group B). Receiver operator characteristic (ROC) curve analysis was performed to evaluate diagnostic value of each index. Area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values were calculated and compared. RESULTS Demographic characteristics were comparable between the two groups. White blood cell (WBC) count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma fibrinogen, plasma D-dimer, platelet count (PC), plateletcrit, and ratio of platelet count to mean platelet volume (PC/MPV) were significantly higher, and MPV and platelet distribution width (PDW) significantly lower, in group A than in group B (P < 0.05). ROC analysis showed PC/MPV and plasma fibrinogen to have better diagnostic value than the other coagulation indicators (AUC of 0.801 and 0.807, respectively). The combination of ESR, plasma fibrinogen, and PC/MPV had good sensitivity and specificity for diagnosis of infected nonunion. PC/MPV had better diagnostic value than ESR and plasma fibrinogen in the subgroup of patients with coagulation-related comorbidities. CONCLUSIONS Plasma fibrinogen and PC/MPV ratio might be useful parameters for early diagnosis of infected nonunion.
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Affiliation(s)
- Zhen Wang
- Department of Orthopedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Hai-Jun Mao
- Department of Orthopedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xu-Sheng Qiu
- Department of Orthopedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yi-Xin Chen
- Department of Orthopedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Guang-Yue Xu
- Department of Orthopedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
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23
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Zhu H, Gao Y, Wang C, Chen Z, Yu X, Qi X, Sun Q, Zhang W, Song W. A nomogram for decision-making assistance on surgical treatment of chronic osteomyelitis in long bones: Establishment and validation based on a retrospective multicenter cohort. Int J Surg 2022; 99:106267. [PMID: 35202861 DOI: 10.1016/j.ijsu.2022.106267] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/04/2022] [Accepted: 02/15/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic osteomyelitis remains a major challenge for orthopedic surgeons due to its high recurrence rate. Surgeons currently have few tools to estimate the likelihood of individual recurrence. We here aimed to develop a nomogram to better estimate individual recurrence rate after surgical treatment of chronic osteomyelitis in long bones. METHODS We first retrospectively identified patients as training cohort who had received surgical treatment of chronic osteomyelitis in long bones between January 2010 and January 2016 from four hospitals. Patient demographic, microbiological, clinical, and therapeutic variables were collected and analyzed. Univariate and multivariate analyses were performed successively to identify independently predictive factors for recurrence. To reduce overfitting, the Bayesian information criterion was used to reduce variables in the original model. Nomograms were created with the reduced model after model selection. The nomogram was then internally validated with bootstrap resampling. We then further validated the performance of the established nomogram in validation cohort (data from two distinct institutions). RESULTS Recurrence was found in 136 of 655 (20.8%) and 52 of 201 patients (25.9%) in training and validation cohorts respectively. We included six independent prognostic factors for recurrence in our prediction model: number of previous recurrences, epiphysial involvement, preoperative serum albumin level, axial length of the infectious lesion, lesion-removal method, and application of a muscular flap. After incorporating these six factors, the nomogram achieved good discrimination, with concordance indexes of 0.82 (95% CI, 0.79-0.85) and 0.80 (95% CI, 0.78-0.83) in predicting recurrence in the training and validation cohorts, respectively. Calibration curves were well fitted for both training and validation cohorts. CONCLUSIONS Our nomogram achieved good preoperative prediction of recurrence in chronic osteomyelitis of long bones. Using this nomogram, the recurrence risk can be confidently predicted for each patient and treatment plan. After considering and discussing the functional prognosis with patients, physicians can establish a rational therapeutic plan. LEVEL OF EVIDENCE Prognostic, Level III.
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Affiliation(s)
- Hongyi Zhu
- Department of Orthopaedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China Shanghai Eighth People's Hospital, Shanghai, China Shanghai Minhang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, China Shanghai Zhujiajiao People's Hospital, Shanghai, China The Fifth Hospital of Wuhan City, Wuhan, Hubei, China Jinghong First People's Hospital, Xishuangbanna, Yunnan, China
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24
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Hellwinkel JE, Working ZM, Certain L, García AJ, Wenke JC, Bahney CS. The intersection of fracture healing and infection: Orthopaedics research society workshop 2021. J Orthop Res 2022; 40:541-552. [PMID: 35076097 PMCID: PMC9169242 DOI: 10.1002/jor.25261] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023]
Abstract
Infection is a common cause of impaired fracture healing. In the clinical setting, definitive fracture treatment and infection are often treated separately and sequentially, by different clinical specialties. The ability to treat infection while promoting fracture healing will greatly reduce the cost, number of procedures, and patient morbidity associated with infected fractures. In order to develop new therapies, scientists and engineers must understand the clinical need, current standards of care, pathologic effects of infection on fractures, available preclinical models, and novel technologies. One of the main causes of poor fracture healing is infection; unfortunately, bone regeneration and infection research are typically approached independently and viewed as two separate disciplines. Here, we aim to bring these two groups together in an educational workshop to promote research into the basic and translational science that will address the clinical challenge of delayed fracture healing due to infection. Statement of clinical significance: Infection and nonunion are each feared outcomes in fracture care, and infection is a significant driver of nonunion. The impact of nonunions on patie[Q2]nt well-being is substantial. Outcome data suggests a long bone nonunion is as impactful on health-related quality of life measures as a diagnosis of type 1 diabetes and fracture-related infection has been shown to significantly l[Q3]ower a patient's quality of life for over 4 years. Although they frequently are associated with one another, the treatment approaches for infections and nonunions are not always complimentary and cannot be performed simultaneously without accepting tradeoffs. Furthermore, different clinical specialties are often required to address the problem, the orthopedic surgeon treating the fracture and an infectious disease specialist addressing the sources of infection. A sequential approach that optimizes treatment parameters requires more time, more surgeries, and thus confers increased morbidity to the patient. The ability to solve fracture healing and infection clearance simultaneously in a contaminated defect would benefit both the patient and the health care system.
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Affiliation(s)
- Justin E Hellwinkel
- Department of Orthopedic Surgery, Columbia University, New York, New York, USA
| | - Zachary M Working
- Department of Orthopaedic Surgery and Rehabilitation, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Laura Certain
- Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
- George E. Wahlen VA Medical Center, Salt Lake City, Utah, USA
| | - Andrés J García
- Woodruff School of Mechanical Engineering and Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Joseph C Wenke
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, Texas, USA
- 7Shriners Children's Texas, Galveston, TX
| | - Chelsea S Bahney
- Center for Regenerative and Personalized Medicine, The Steadman Clinic & Steadman Philippon Research Institute, Vail, Colorado, USA
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF), San Francisco, California, USA
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25
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Clausen JD, Mommsen P, Omar Pacha T, Winkelmann M, Krettek C, Omar M. [Management of fracture-related infections]. Unfallchirurg 2021; 125:41-49. [PMID: 34932139 DOI: 10.1007/s00113-021-01116-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 12/19/2022]
Abstract
Fracture-related infections (FRI) are a major challenge in orthopedic trauma surgery. The problems in the treatment of such infections are manifold. Especially in cases with insufficient fracture consolidation the treatment not only focusses on the eradication of the infection but also on the restoration of the osseous continuity. The extent of the accompanying soft tissue damage is of particular importance as reduced vascularization leads to impairments in fracture healing. Although acute infections are frequently easy to recognize, the symptoms of chronic infections can be unspecific and evade the diagnostic procedures. This fact makes the treatment of such infections complicated and sometimes necessitates an interdisciplinary approach. For this reason, the Fracture-related Infection Consensus Group developed an algorithm, which was first published in 2017 and revised in 2018 and 2020. The FRIs are biofilm-associated infections, so that the current guidelines follow the previously established treatment algorithms for periprosthetic infections. Despite the analogies to periprosthetic infections there are also differences in the treatment as the aspects of fracture healing and bone defect restoration represent determining factors in the treatment of FRI. This article presents the special features of FRI and the classification and guidelines for the treatment are discussed.
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Affiliation(s)
- Jan-Dierk Clausen
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Philipp Mommsen
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Tarek Omar Pacha
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Marcel Winkelmann
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Christian Krettek
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Mohamed Omar
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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Interleukin-6 versus Common Inflammatory Biomarkers for Diagnosing Fracture-Related Infection: Utility and Potential Influencing Factors. J Immunol Res 2021; 2021:1461638. [PMID: 34595243 PMCID: PMC8478596 DOI: 10.1155/2021/1461638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022] Open
Abstract
Currently, the utility of white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), for diagnosis of fracture-related infection (FRI), is still controversial, and potential efficiency of interleukin-6 (IL-6) as a novel cytokine in assisted diagnosis of FRI remains unclear. This study is aimed at investigating the utility and potential influencing factors of IL-6 and the common biomarkers for diagnosing FRI. Preoperative serological levels of IL-6 and the three biomarkers were compared between 407 FRI patients and 195 fracture-healed (FH) patients. Diagnostic efficiency of the indicators was evaluated using the areas under the receiver operating characteristic (ROC) curves, and their potential influencing factors were also analyzed. Outcomes showed that the median levels of all of the four biomarkers were significantly higher among the FRI patients than those among the FH patients (P < 0.01). The areas below the ROC curves of ESR, CRP, and IL-6 were 76.5%, 76.4%, and 71.8%, respectively, with WBC of only 56.9%. Compared with ESR and CRP, IL-6 displayed a lower sensitivity (ESR vs. CRP vs. IL − 6 = 72.7% vs. 65.6% vs. 57.5%) but a higher specificity (ESR vs. CRP vs. IL − 6 = 70.3% vs. 75.4% vs. 83.6%). Serological IL-6 level was influenced by pathogen culture result and pathogen number; nonetheless, bacteria type appeared to have no influence on the levels of the four biomarkers. In short, this study displayed similar value of IL-6 with that of ESR and CRP in assisted diagnosis of FRI. Whether IL-6 can be regarded as a promising diagnostic indicator requires more studies.
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Gemmel F, Van den Broeck B, Vanelstraete S, Van Innis B, Huysse W. Hybrid imaging of complicating osteomyelitis in the peripheral skeleton. Nucl Med Commun 2021; 42:941-950. [PMID: 33852533 DOI: 10.1097/mnm.0000000000001421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Diagnosing complicating osteomyelitis (COM) is clinically challenging. Laboratory tests are of limited utility, and other than isolation of the offending organism, diagnostic imaging tests are of paramount importance. Nuclear Medicine techniques play an important role in noninvasive evaluation of osteomyelitis, using both single-photon emission tomography (SPECT) and positron emission tomography (PET) radiopharmaceuticals. It is well-known that those conventional imaging modalities are not performing well in the distinction between soft-tissue and deep bone infection due to the lack of anatomical information. These difficulties have been overcome, to a great extent, with the introduction of in-line SPECT-CT and PET-CT systems which have revolutionized the field of diagnostic medical imaging. Hybrid imaging is especially useful in sites of suspected COM with underlying structural bone alterations. The first clinical studies with these integrated hybrid machines in the field of COM, including metallic implants imaging, are highly promising. In summary, WBC/AGA SPECT-CT and FDG-PET-CT seem to be the most accurate hybrid imaging modality for COM of the peripheral bone. However, there are still false positives, especially in aseptic tibial nonunions and/or metallic implants, as well as in the immediate postoperative setting. Furthermore, there is a lack of well-designed large multicentre prospective studies. Hopefully, in the future, the complementary use of morphological and functional hybrid imaging modalities may overcome some of the challenges faced in the assessment of COM.
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Affiliation(s)
- Filip Gemmel
- Department of Nuclear Medicine, General Hospital Oudenaarde and University Hospital Ghent
- Department of Nuclear Medicine, University Hospital Ghent
| | | | | | - Benoit Van Innis
- Department of Orthopaedic Surgery and Traumatology, General Hospital Oudenaarde
| | - Wouter Huysse
- Department of Radiology and Molecular Imaging, University Hospital Ghent, Ghent, Belgium
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Goh GS, Tornetta P, Parvizi J. Facilitating the Approval Process of Anti-Infective Technologies and Advancing Them to the Market: Insights from an FDA Workshop on Orthopaedic Device-Related Infections. J Bone Joint Surg Am 2021; 103:e57. [PMID: 34357892 DOI: 10.2106/jbjs.21.00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Orthopaedic device-related infection is one of the most devastating complications in orthopaedic and trauma surgery. With increasing life expectancies as well as the lifelong risk of bacterial seeding on an implant, the prevention and treatment of device-related infection remains an important area for research and development. To facilitate information exchange and enhance collaboration among various stakeholders in the orthopaedic community, the U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) organized an inaugural workshop on orthopaedic device-related infections, exploring the regulatory challenges that are faced when proceeding from the bench level to marketing and clinical implementation of new infection-control devices and products. This article summarizes the perspectives of scientists, clinicians, and industry partners on the current regulatory approval process for orthopaedic anti-infective technologies as well as the proposed strategies to overcome these regulatory challenges.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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29
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Abstract
Accurate diagnosis of fracture related infection (FRI) is critical for preventing poor outcomes such as loss of function or amputation. Due to the multiple variables associated with FRI, however, accurate diagnosis is challenging and complicated by a lack of standardized diagnostic criteria. Limitations with the current gold standard for diagnosis, which is routine microbiology culture, further complicate the diagnostic and management process. Efforts to optimize the process rely on a foundation of data derived from prosthetic joint infections (PJI), but differences in PJI and FRI make it clear that unique approaches for these distinct infections are required. A more concerted effort focusing on FRI has dominated more recent investigations and publications leading to a consensus definition by the American Orthopedics (AO) Foundation and the European Bone and Joint Infection Society (EBJIS). This has the potential to better standardize the diagnostic process, which will not only improve patient care but also facilitate more robust and reproducible research related to the diagnosis and management of FRI. The purpose of this review is to explore the consensus definition, describe the foundation of data supporting current FRI diagnostic techniques, and identify pathways for optimization of clinical microbiology-based strategies and data.
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30
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Li C, Renz N, Trampuz A, Ojeda-Thies C. The value of conventional radiographs for diagnosing internal fixation-associated infection. BMC Musculoskelet Disord 2021; 22:411. [PMID: 33947369 PMCID: PMC8097790 DOI: 10.1186/s12891-021-04170-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
Background The aim of the study is to assess the diagnostic value of preoperative conventional radiographs for diagnosing infection associated with internal fixation devices. Methods We prospectively collected data of patients undergoing removal of internal fixation devices for any reason. Infection was diagnosed in case of purulence, sinus tract, positive histopathology and/or positive peri-implant tissue or sonication fluid culture. In radiographs radiolucent lines, implant breakage or displacement, or periosteal reaction were assessed. White blood cell count (WBC) and serum C-reactive protein (CRP) were determined at admission. Results We included 421 surgeries in 380 patients (median age 53.6 years, range 11–98 years), mainly indicated for infection (24.9%), nonunion (20.0%) and symptomatic implants (13.5%). Radiologic signs of infection included radiolucent lines (11.4%); implant breakage (12.4%) or displacement (10.7%); and periosteal reaction (7.1%). Infection was confirmed in 116 cases (27.6%). Only radiolucent lines (OR = 1.86 [95%CI: 1.00–3.38]) and periosteal reaction (OR = 2.48 [95%CI: 1.17–5.26]) were associated with infection, with a low sensitivity (16.4 and 12.1%, respectively), and high specificity (90.5 and 94.8%, respectively). Preoperative WBC and CRP had a sensitivity of 23.0 and 35.3%, and specificity of 91.7 and 89.5%, respectively. Conclusions Radiological signs suggestive of infection were uncommon. Radiolucency and periosteal reaction were associated with infection, though with low sensitivity. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04170-3.
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Affiliation(s)
- Cheng Li
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Mittelallee 3, 13353, Berlin, Germany
| | - Nora Renz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Mittelallee 3, 13353, Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Mittelallee 3, 13353, Berlin, Germany.
| | - Cristina Ojeda-Thies
- Department of Traumatology and Orthopedic Surgery, Hospital Universitario 12 de Octubre, Avda Córdoba s/n, 28041, Madrid, Spain
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31
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Saul D, Hünicke P, Böker KO, Spering C, Maheshwari AK, Acharya M, Lehmann W. Predicting the disaster - The role of CRP in acetabular surgery. Clin Biochem 2021; 94:48-55. [PMID: 33895126 DOI: 10.1016/j.clinbiochem.2021.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Acetabular fractures represent a complex surgical challenge. Given the heterogenous fracture pattern, the patient characteristics and spectrum of complications demand individual solutions. Surgical site infections (SSI) threaten osteosynthesis, and early detection of them and treatment remain crucial. What is the value of postoperative C-reactive protein (CRP) in this group of patients as well as its normal course? DESIGN & METHODS 115 patients with isolated fractures of the acetabulum were retrospectively evaluated. CRP, white blood cell count (WBC) and fracture patterns as well as patient characteristics were assessed for 20 days following operative fixation of the acetabular fracture (n = 71) and in fractures that were managed conservatively (n = 44). RESULTS Twelve patients suffered an infectious complication. With a one-phase decay, 70.55% of the variance of postoperative CRP kinetics was predicted. To anticipate maximum CRP as well as an infection, the preoperative CRP represented the best prognostic parameter. To predict an infection, the single variable "peak CRP value above 100 mg/l" resulted in a sensitivity and specificity of 91.67% and 36.21%, respectively. Combining a second peak of CRP with maximum CRP and day 5 CRP value for receiver-operating characteristic (ROC) analysis resulted in 83.3% and 88.1%, respectively. CONCLUSIONS Predicting surgical site infections after an acetabular fracture is most predictive when analyzing the maximum overall CRP, the second peak and the CRP after day 5. With a combination of these parameters, a sensitivity and specificity of 83.3% and 88.1% to detect an infection was achieved.
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Affiliation(s)
- D Saul
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, Germany; Kogod Center on Aging and Division of Endocrinology, Mayo Clinic, Rochester, MN 55905, USA.
| | - P Hünicke
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, Germany
| | - K O Böker
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, Germany
| | - C Spering
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, Germany
| | - A K Maheshwari
- Kogod Center on Aging and Division of Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
| | - M Acharya
- Trauma & Orthopaedics, Southmead Hospital, Bristol BS10 5NB, United Kingdom
| | - W Lehmann
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, Germany
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Abstract
OBJECTIVES To determine the factors associated with successful union and eradication of infection in the setting of staged procedures to treat obviously infected nonunions of long bones. We hypothesize that patients with positive intraoperative cultures obtained at the time of definitive surgery for infected nonunions are more likely to have persistent nonunion than those with negative cultures. DESIGN Multicenter retrospective review. SETTING Eight academic Level 1 trauma centers. PATIENTS/PARTICIPANTS Patients who underwent staged management for obviously infected nonunion of a long bone. MAIN OUTCOME MEASUREMENTS For each patient, initial fracture management, management of retained implants, number of debridements, grafting, bacteriology, antibiotic course, bone defect management, soft-tissue coverage, and definitive surgery performed were reviewed. RESULTS A total of 134 patients were treated with staged procedures for obviously infected nonunion of a long bone (mean age 49 years, 60% open fractures, and mean follow-up 22 months). During definitive procedures, 120 patients had intraoperative cultures taken with 43% having positive cultures. For culture-positive patients, 41 patients achieved eventual union and 10 had persistent nonunion. Of 69 culture-negative patients, 66 achieved eventual union and 3 had persistent nonunion. The number of patients with union versus persistent nonunion was statistically significant between culture-positive and culture-negative groups (P = 0.015). CONCLUSIONS Management of infected nonunion in long bones with staged treatments before definitive fixation are beneficial but ultimately less effective when performed in the setting of positive bacterial cultures at the time of definitive management. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Yagi H, Kihara S, Mittwede PN, Maher PL, Rothenberg AC, Falcione ADCM, Chen A, Urish KL, Tuan RS, Alexander PG. Development of a large animal rabbit model for chronic periprosthetic joint infection. Bone Joint Res 2021; 10:156-165. [PMID: 33641351 PMCID: PMC8005337 DOI: 10.1302/2046-3758.103.bjr-2019-0193.r3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Aims Periprosthetic joint infections (PJIs) and osteomyelitis are clinical challenges that are difficult to eradicate. Well-characterized large animal models necessary for testing and validating new treatment strategies for these conditions are lacking. The purpose of this study was to develop a rabbit model of chronic PJI in the distal femur. Methods Fresh suspensions of Staphylococcus aureus (ATCC 25923) were prepared in phosphate-buffered saline (PBS) (1 × 109 colony-forming units (CFUs)/ml). Periprosthetic osteomyelitis in female New Zealand white rabbits was induced by intraosseous injection of planktonic bacterial suspension into a predrilled bone tunnel prior to implant screw placement, examined at five and 28 days (n = 5/group) after surgery, and compared to a control aseptic screw group. Radiographs were obtained weekly, and blood was collected to measure ESR, CRP, and white blood cell (WBC) counts. Bone samples and implanted screws were harvested on day 28, and processed for histological analysis and viability assay of bacteria, respectively. Results Intraosseous periprosthetic introduction of planktonic bacteria induced an acute rise in ESR and CRP that subsided by day 14, and resulted in radiologically evident periprosthetic osteolysis by day 28 accompanied by elevated WBC counts and histological evidence of bacteria in the bone tunnels after screw removal. The aseptic screw group induced no increase in ESR, and no lysis developed around the implants. Bacterial viability was confirmed by implant sonication fluid culture. Conclusion Intraosseous periprosthetic introduction of planktonic bacteria reliably induces survivable chronic PJI in rabbits. Cite this article: Bone Joint Res 2021;10(3):156–165.
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Affiliation(s)
- Haruyo Yagi
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shinsuke Kihara
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter N Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Patrick L Maher
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam C Rothenberg
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alyssa D C M Falcione
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Antonia Chen
- Department of Orthopaedic Surgery, Center for Cellular and Molecular Engineering, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Arthritis and Arthroplasty Design Group, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Rocky S Tuan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Chen CH, Chang IL, Wang SH, Yen HC, Lin JS, Lo SC, Huang CC. Potential novel proteomic biomarkers for diagnosis of vertebral osteomyelitis identified using an immunomics protein array technique: Two cases reports. Medicine (Baltimore) 2020; 99:e22852. [PMID: 33120821 PMCID: PMC7581026 DOI: 10.1097/md.0000000000022852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Although vertebral osteomyelitis (VO) is commonly associated with high morbidity and high recurrence rate, effective diagnostic and prognostic biomarkers of VO are still lacking. PATIENTS CONCERNS Case 1: a 60-year-old male had had upper back pain for 3 days. Case 2: a 71-year-old female presented upper back pain for 2 days. DIAGNOSES Based on physical examination and findings of magnetic resonance imaging and findings by matrix-assisted laser desorption ionization-time of flight mass spectrometry, they were diagnosed with Staphylococcus aureus VO. INTERVENTIONS Using Sengenics Immunome Protein Array by analyzing autoantibodies in both VO patients, potential biomarkers of VO were explored. OUTCOMES Four subjects with more than 1600 antigens screened while the results showed that 14-3-3 protein gamma, pterin-4-alpha-carbinolamine dehydratase, fructose-bisphosphate aldolase A, and keratin type II cytoskeletal 8 were highly differentially expressed among VO and controls. Relevant auto-antibody profiles were discovered after intra-group and inter-group comparison, and based on functional rationality, an adapter protein 14-3-3 protein gamma, and pterin-4-alpha-carbinolamine dehydratase that involved in tetrahydrobiopterin biosynthesis, might serve as valuable diagnostic biomarkers. LESSONS This pilot study on 4 subjects with more than 1600 antigens screened on the Sengenics Immunome protein array provided a general outlook on autoantibody biomarker profiles of VO subjects. Future large-scale trials with longer follow-up times are warranted.
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Affiliation(s)
- Chang-Hua Chen
- Division of Infectious Disease, Department of Internal Medicine
- Center for Infection Prevention and Control, Changhua Christian Hospital, Changhua
- Ph.D. Program in Translational Medicine, National Chung Hsing University
- Rong Hsing Research Center For Translational Medicine, National Chung Hsing University, Taichung City
| | | | | | | | - Jen-Shiou Lin
- Department of Laboratory Medicine, Changhua Christian Hospital, Changhua
| | | | - Chieh-Chen Huang
- Ph.D. Program in Translational Medicine, National Chung Hsing University
- Department of Life Sciences
- PhD Program in Medical Biotechnology, National Chung Hsing University, Taichung City, Taiwan
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McNally M, Govaert G, Dudareva M, Morgenstern M, Metsemakers WJ. Definition and diagnosis of fracture-related infection. EFORT Open Rev 2020; 5:614-619. [PMID: 33204503 PMCID: PMC7608516 DOI: 10.1302/2058-5241.5.190072] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Fracture-related infection (FRI) is common and often diagnosed late.Accurate diagnosis is the beginning of effective treatment.Diagnosis can be difficult, particularly when there are no outward signs of infection.The new FRI definition, together with clear protocols for nuclear imaging, microbiological culture and histological analysis, should allow much better study design and a clearer understanding of infected fractures.In recent years, there has been a new focus on defining FRI and avoiding non-specific, poorly targeted treatment. Previous studies on FRI have often failed to define infection precisely and so are of limited value. This review highlights the essential principles of making the diagnosis and how clinical signs, serum tests, imaging, microbiology, molecular biology and histology all contribute to the diagnostic pathway. Cite this article: EFORT Open Rev 2020;5:614-619. DOI: 10.1302/2058-5241.5.190072.
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Affiliation(s)
- Martin McNally
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Geertje Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria Dudareva
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
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Tsang STJ, Eyre DW, Atkins BL, Simpson AHRW. Should modern molecular testing be routinely available for the diagnosis of musculoskeletal infection? Bone Joint J 2020; 102-B:1274-1276. [DOI: 10.1302/0301-620x.102b10.bjj-2020-1496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- S-T. Jerry Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
- Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David W. Eyre
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Bridget L. Atkins
- Bone Infection Unit, Nuffield Orthopaedic Hospital, Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Qin L, Li X, Wang J, Gong X, Hu N, Huang W. Improved diagnosis of chronic hip and knee prosthetic joint infection using combined serum and synovial IL-6 tests. Bone Joint Res 2020; 9:587-592. [PMID: 33005398 PMCID: PMC7502257 DOI: 10.1302/2046-3758.99.bjr-2020-0095.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aims This study aimed to explore whether serum combined with synovial interleukin-6 (IL-6) measurement can improve the accuracy of prosthetic joint infection (PJI) diagnosis, and to establish the cut-off values of IL-6 in serum and synovial fluid in detecting chronic PJI. Methods Patients scheduled to have a revision surgery for indications of chronic infection of knee and hip arthroplasties or aseptic loosening of an implant were prospectively screened before being enrolled into this study. The Musculoskeletal Infection Society (MSIS) definition of PJI was used for the classification of cases as aseptic or infected. Serum CRP, ESR, IL-6, and percentage of polymorphonuclear neutrophils (PMN%) and IL-6 in synovial fluid were analyzed. Statistical tests were performed to compare these biomarkers in the two groups, and receiver operating characteristic (ROC) curves and area under the curve (AUC) were analyzed for each biomarker. Results A total of 93 patients were enrolled. There was no difference in demographic data between both groups. Synovial fluid IL-6, with a threshold of 1,855.36 pg/ml, demonstrated a mean sensitivity of 94.59% (95% confidence interval (CI) 81.8% to 99.3%) and a mean specificity of 92.86% (95% CI 82.7 to 98.0) for detecting chronic PJI. Then 6.7 pg/ml was determined to be the optimal threshold value of serum IL-6 for the diagnosis of chronic PJI, with a mean sensitivity of 97.30% (95% CI 85.8% to 99.9%) and a mean specificity of 76.79% (95% CI 63.6% to 87.0%). The combination of synovial IL-6 and serum IL-6 led to improved accuracy of 96.77% in diagnosing chronic PJI. Conclusion The present study identified that a combination of IL-6 in serum and synovial IL-6 has the potential for further improvement of the diagnosis of PJI.Cite this article: Bone Joint Res 2020;9(9):587-592.
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Affiliation(s)
- Leilei Qin
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xinyu Li
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiawei Wang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuan Gong
- Outpatient Department, Chongqing First People's Hospital, Chongqing, China
| | - Ning Hu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Metsemakers WJ, Morgenstern M, Senneville E, Borens O, Govaert GAM, Onsea J, Depypere M, Richards RG, Trampuz A, Verhofstad MHJ, Kates SL, Raschke M, McNally MA, Obremskey WT. General treatment principles for fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg 2020; 140:1013-1027. [PMID: 31659475 PMCID: PMC7351827 DOI: 10.1007/s00402-019-03287-4] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Indexed: 12/15/2022]
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.
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Affiliation(s)
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Eric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, University of Lille, Lille, France
| | - Olivier Borens
- Orthopedic Department of Septic Surgery, Orthopaedic-Trauma Unit, Department for the Musculoskeletal System, CHUV, Lausanne, Switzerland
| | - Geertje A M Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael H J Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, USA
| | - Michael Raschke
- Department of Trauma Surgery, University Hospital of Münster, Münster, Germany
| | - Martin A 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, TN, USA
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Sigmund IK, Dudareva M, Watts D, Morgenstern M, Athanasou NA, McNally MA. Limited diagnostic value of serum inflammatory biomarkers in the diagnosis of fracture-related infections. Bone Joint J 2020; 102-B:904-911. [PMID: 32600147 DOI: 10.1302/0301-620x.102b7.bjj-2019-1739.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AIMS The aim of this study was to evaluate the diagnostic value of preoperative serum CRP, white blood cell count (WBC), percentage of neutrophils (%N), and neutrophil to lymphocyte ratio (NLR) when using the fracture-related infection (FRI) consensus definition. METHODS A cohort of 106 patients having surgery for suspected septic nonunion after failed fracture fixation were studied. Blood samples were collected preoperatively, and the concentration of serum CRP, WBC, and differential cell count were analyzed. The areas under the curve (AUCs) of diagnostic tests were compared using the z-test. Regression trees were constructed and internally cross-validated to derive a simple diagnostic decision tree. RESULTS Using the FRI consensus definition, 46 patients (43%) were identified as infected. Sensitivity, specificity, and AUC of CRP were 67% (95% confidence interval (CI) 52% to 80%), 61% (95% CI 47% to 74%), and 0.64 (95% CI 0.54 to 0.74); of WBC count were 17% (95% CI 9% to 31%), 95% (95% CI 86% to 99%), and 0.57 (95% CI 0.50 to 0.62); of %N 13% (95% CI 6% to 26%), 87% (95% CI 76% to 93%), and 0.50 (95% CI 0.43 to 0.56); and of NLR 28% (95% CI 17% to 43%), 80% (95% CI 68% to 88%), and 0.54 (95% CI 0.46 to 0.63), respectively. A better performance of serum CRP was shown in comparison to the leucocyte count (p = 0.006), %N (p < 0.001), and NLR (p = 0.001). A statistically lower serum CRP level was shown in patients with an infection caused by a low virulence microorganism in comparison to high virulence bacteria (p = 0.008). We found that a simple decision tree approach using only low serum neutrophils (< 3.615 × 109/l) and low CRP (< 2.45 mg/l) may allow better identification of aseptic cases. CONCLUSION The evaluated serum inflammatory markers showed limited diagnostic value in the preoperative diagnosis of FRI when using the uniform FRI Consensus Definition. Therefore, they should remain as suggestive criteria in diagnosing FRI. Although CRP showed a higher performance in comparison to the other serum markers, it is insufficiently accurate to diagnose a septic nonunion, especially when caused by low virulence microorganisms. Cite this article: Bone Joint J 2020;102-B(7):904-911.
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Affiliation(s)
- Irene K Sigmund
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK.,Medical University of Vienna, Department of Orthopaedics and Trauma Surgery, Vienna, Austria
| | - Maria Dudareva
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - Daniel Watts
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - Mario Morgenstern
- Department of Orthopaedic Surgery and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Nicholas A Athanasou
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
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Obremskey WT, Metsemakers WJ, Schlatterer DR, Tetsworth K, Egol K, Kates S, McNally M. Musculoskeletal Infection in Orthopaedic Trauma: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection. J Bone Joint Surg Am 2020; 102:e44. [PMID: 32118653 DOI: 10.2106/jbjs.19.01070] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fracture-related infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.
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Affiliation(s)
- William T Obremskey
- Department of Orthopaedic Trauma, Vanderbilt Medical Center, Nashville, Tennessee
| | | | | | - Kevin Tetsworth
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia.,Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Kenneth Egol
- Department of Orthopedic Surgery, NYU School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Stephen Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Martin McNally
- Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
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Govaert GAM, Kuehl R, Atkins BL, Trampuz A, Morgenstern M, Obremskey WT, Verhofstad MHJ, McNally MA, Metsemakers WJ. Diagnosing Fracture-Related Infection: Current Concepts and Recommendations. J Orthop Trauma 2020; 34:8-17. [PMID: 31855973 PMCID: PMC6903359 DOI: 10.1097/bot.0000000000001614] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 02/02/2023]
Abstract
Fracture-related infection (FRI) is a severe complication after bone injury and can pose a serious diagnostic challenge. Overall, there is a limited amount of scientific evidence regarding diagnostic criteria for FRI. For this reason, the AO Foundation and the European Bone and Joint Infection Society proposed a consensus definition for FRI to standardize the diagnostic criteria and improve the quality of patient care and applicability of future studies regarding this condition. The aim of this article was to summarize the available evidence and provide recommendations for the diagnosis of FRI. For this purpose, the FRI consensus definition will be discussed together with a proposal for an update based on the available evidence relating to the diagnostic value of clinical parameters, serum inflammatory markers, imaging modalities, tissue and sonication fluid sampling, molecular biology techniques, and histopathological examination. Second, recommendations on microbiology specimen sampling and laboratory operating procedures relevant to FRI will be provided. LEVEL OF EVIDENCE:: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Geertje A. M. Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Richard Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - Bridget L. Atkins
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Michael H. J. Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; and
| | - Martin A. McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
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Lapić I, Padoan A, Bozzato D, Plebani M. Erythrocyte Sedimentation Rate and C-Reactive Protein in Acute Inflammation. Am J Clin Pathol 2020; 153:14-29. [PMID: 31598629 DOI: 10.1093/ajcp/aqz142] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess the diagnostic accuracy of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in acute inflammation. METHODS PubMed and Scopus were searched and eligible articles were screened for methodologic quality using the Quality Assessment of the Diagnostic Accuracy Studies-Revised. Meta-analysis with calculation of pooled sensitivity (Se), specificity (Sp), and summary area under the curve (SAUC) was performed. RESULTS Twenty-nine studies were eligible. Se and Sp were 0.78 and 0.68 (SAUC = 0.80) for ESR in orthopedic infections and 0.79 and 0.70 (SAUC = 0.81) for CRP. For the diagnosis of other various inflammatory conditions, CRP had a superior diagnostic accuracy, with a Se of 0.86, Sp of 0.67, and SAUC of 0.86 compared with a Se of 0.77, Sp of 0.59, and SAUC of 0.75 for ESR. Heterogeneity among studies was elevated. Combined use of ESR and CRP yielded higher diagnostic accuracy. CONCLUSIONS Despite observed heterogeneity among studies, ESR and CRP have a similar diagnostic accuracy in assessment of inflammation, especially in orthopedic conditions.
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Affiliation(s)
- Ivana Lapić
- Department of Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Andrea Padoan
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- Department of Medicine–DIMED, University of Padova, Padova, Italy
| | - Dania Bozzato
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- Department of Medicine–DIMED, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- Department of Medicine–DIMED, University of Padova, Padova, Italy
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44
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Pathogenesis and management of fracture-related infection. Clin Microbiol Infect 2019; 26:572-578. [PMID: 31446152 DOI: 10.1016/j.cmi.2019.08.006] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/09/2019] [Accepted: 08/10/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Both fracture-related infections (FRIs) and periprosthetic joint infections (PJIs) include orthopaedic implant-associated infections. However, key aspects of management differ due to the bone and soft tissue damage in FRIs and the option of removing the implant after fracture healing. In contrast to PJIs, research and guidelines for diagnosis and treatment in FRIs are scarce. OBJECTIVES This narrative review aims to update clinical microbiologists, infectious disease specialists and surgeons on the management of FRIs. SOURCES A computerized search of PubMed was performed to identify relevant studies. Search terms included 'Fracture' and 'Infection'. The reference lists of all retrieved articles were checked for additional relevant references. In addition, when scientific evidence was lacking, recommendations are based on expert opinion. CONTENT Pathogenesis, prevention, diagnosis and treatment of FRIs are presented. Whenever available, specific data of patients with FRI are discussed. IMPLICATIONS Management of patients with FRI should take into account FRI-specific features. Treatment pathways should implement a multidisciplinary approach to achieve a good outcome. Recently, international consensus guidelines were developed to improve the quality of care for patients suffering from this severe complication, which are highlighted in this review.
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The effect of early broad-spectrum versus delayed narrow-spectrum antibiotic therapy on the primary cure rate of acute infection after osteosynthesis. Eur J Trauma Emerg Surg 2019; 46:1341-1350. [PMID: 31312856 PMCID: PMC7691296 DOI: 10.1007/s00068-019-01182-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 07/05/2019] [Indexed: 12/05/2022]
Abstract
Purpose Infection near metal implants is a problem that presents challenging treatment dilemmas for physicians. The aim of this study was to analyse the efficacy of two treatment protocols for acute fracture-related infections. Methods Seventy-one patients in two level-1 trauma centres in the Netherlands were retrospectively included in this study. These trauma centres had different standardised protocols for acute infection after osteosynthesis: 39 patients were selected from protocol A and 32 from protocol B. Both protocols involve immediate surgical debridement and soft tissue coverage, but differ in antibiotic approach: (A) immediate empirical combination antibiotic therapy with rifampicin, or (B) postponed (1–5 days) targeted antibiotic therapy. The primary outcome of these protocols was success, defined as a fracture healing in the absence of infection. The secondary outcome was antibiotic resistance patterns. Logistic regression was conducted on patients and treatment-related factors in association with primary success. Results Primary success was achieved in 72% of protocol A patients, in 47% of those in protocol B (P = 0.033), and with prolongation of treatment success was achieved in 90% and 78% of patients, respectively. Protocol A exhibited a better primary success rate (adjusted OR 3.45, CI 1.13–10.52) when adjusted for age and soft tissue injury. There was no significant difference in antibiotic resistance between the two protocols. Conclusion Both protocols yielded high overall success rates. Immediate empirical antibiotics can be used safely without additional bacterial resistance and may contribute to increased success rates.
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