Management of fracture-related infection in low resource settings: how applicable are the current consensus guidelines?

Highly-Cited Papers on Fracture Non-union - A Bibliometric Analysis of the Global Literature (1990-2023)

Objective

The growing interest in this field of fracture nonunion has been informally acknowledged through published studies. A bibliometric analysis was conducted to objectively outline the patterns in published clinical research concerning nonunion fractures by utilizing highly cited papers (HCPs).

Methods

Through a predetermined search strategy, we gathered literature on the clinical management of nonunion fractures from the Scopus database and utilized bibliometrics to examine the publication dates, countries, institutions, journals, authors, HCPs, and research focal points. Statistical analysis and visualization were conducted using MS Excel and VOSviewer software.

Results

From 1990 to 2023, a total of 168 HCPs in the field of fracture nonunion were identified. They received an average of 167.68 citations per paper (CPP). Among them, 4.08% received external funding, while 17.26% were involved in international collaboration. The United States (49.4% share) was the most productive country and France had the highest citation impact. P.V. Gianoudis had the highest productivity with 13 publications and P. Hernigou had the highest citation impact. The Mayo Clinic was the most productive organization and Hopital Henri Mondor achieved the highest citation impact. The most productive journal was Clinical Orthopedics & Related Research, and the Journal of Bone & Joint Surgery, American Volume had the highest average citation impact.

Conclusion

This contemporary bibliometric study illustrates the research features and developments of nonunion fractures. Through the use of VOSviewer, key countries, organizations, and authors could be identified, providing researchers with essential information to pinpoint current and future areas of interest in fracture nonunion.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-024-01176-6.

The FRI classification - A new classification of fracture-related infections

AIM

To identify the most relevant factors with respect to the management of fracture-related infection (FRI) and to develop a comprehensive FRI classification that guides decision-making and allows scientific comparison.

METHOD

An international group of FRI experts determined the preconditions, purpose, primary factors for inclusion, format and detailed description of the elements of an FRI classification through a consensus driven process.

RESULTS

Three major elements were identified and grouped together in the FRI Classification: Fracture (F), Related patient factors (R) and Impairment of soft tissues (I). Each element was divided into five levels of complexity. Fractures can be healed (F1) or unhealed (F2-5). Patients may be fully healthy (R1) or have 4 levels of compromise, with and without end-organ damage (R2-5). Soft tissue condition ranges from well vascularized and easily closed (I1) to major skin defects requiring free flaps (I4). In all three elements, the fifth level (F5, R5 or I5) describes a patient who has an unreconstructible bone, soft tissue envelope or is not fit for surgery.

CONCLUSION

The FRI classification, which is based on the three major elements Fracture (F), Related patient factors (R) and Impairment of soft tissues (I) is intended to guide decision-making and improve the quality of scientific reporting for FRIs in the future. The proposed classification is based on expert opinion and therefore an essential next step is clinical validation, in order to realize the ultimate goal of improving outcomes in the management of FRI.

Recent advancements and future directions in fracture related infections: A scoping review

Fracture-related infections (FRIs) are complex challenges in orthopedic and trauma surgery, driving ongoing advancements in diagnostics, therapeutics, and management strategies. This scoping review examines recent progress and future directions in FRI management. Diagnostic enhancements encompass standardized definitions, improved biomarkers, advanced microbiological techniques, and innovative imaging modalities. Promising future diagnostics may include point-of-care testing, advanced imaging with enhanced specificity, and machine learning algorithms. Advancements in implant technology emphasize materials science, surface modifications, and personalized 3D printing, enhancing durability and antimicrobial efficacy. Immunomodulatory therapies targeting T cell dysfunction offer potential in addressing FRI chronicity. Enzybiotics and phages present promising alternatives to combat antibiotic resistance, with enzybiotics demonstrating effectiveness against biofilm-associated infections. Patient optimization, multidisciplinary approaches and specialized reference centers play vital roles in comprehensive FRI management, particularly crucial in resource-constrained settings. Collaboration and investment in research and technology are imperative for harnessing the full potential of these advancements and improving global FRI management outcomes. Addressing these complexities necessitates a multifaceted approach integrating clinical expertise, technological innovation, and global cooperation to optimize patient care and mitigate the burden of FRI worldwide.

Is there a role for suppression of infection in managing fracture-related infection following intra-medullary nailing?

BACKGROUND

The management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection.

METHODS

A retrospective review of consecutive patients treated with initial antimicrobial suppression to support fracture healing followed by definitive eradication surgery to manage fracture-related infections following intramedullary fixation was performed. Indications for this approach were; a soft tissue envelope not requiring reconstructive surgery, radiographic evidence of stable fixation with adequate alignment, and progression towards fracture union.

RESULTS

This approach was associated with successful treatment in 51/55 (93 %) patients. Fracture union was achieved in 52/55 (95 %) patients with antimicrobial suppression alone. Remission of infection was achieved in 54/55 (98 %) patients following definitive infection eradication surgery. Following antibiotic suppression, 6/46 (13 %) pathogens isolated from intra-operative samples demonstrated multi-drug resistance.

CONCLUSION

Initial antimicrobial suppression to support fracture healing followed by definitive infection eradication surgery was associated with successful treatment in 93 % of patients. The likelihood of remission of infection increases when eradication surgery is performed in a healed bone. This approach was not associated with an increased risk of developing multi-drug-resistant infections compared to contemporary bone infection cohorts in the published literature.

LEVEL OF EVIDENCE

IV.

A meta-analysis of the incidence of infections following open tibia fractures and the microorganisms that cause them in high-, middle- and low-income countries

Open tibia fractures are devastating, life changing injuries, with infection associated with substantial morbidity to the patient. Reducing infection is a research priority, but before interventional studies can be designed, the incidence of infection following this injury needs to be better defined. Our aim was to estimate the global incidence of infection following an open tibia fracture. A systematic review was performed of MEDLINE, EMBASE, Central Register of Controlled Trials (CENTRAL), Web of Science and Global Index Medicus. We included randomised controlled trials with more than ten participants which reported infections after open diaphyseal or distal fractures (AO 42 or 43). Primary outcome was deep infection according to the Centres for Disease Control and Prevention criteria. Secondary outcome included causative micro-organisms. A meta-analysis using a random effects model to assess incidence and between-treatment effects was performed. Thirteen studies including 1463 adults from seven middle-income countries, seven high-income countries and one low-income country were included. The incidence of infection was 12.12 person-years (95% CI 7.95-18.47). A subgroup analysis compared external fixation and intramedullary nailing showed no difference between infection rates. There were limited data on organisms, but Staphylococcus aureus was the most commonly identified. There are limited to no data on antimicrobial resistance.

The global burden of fracture-related infection: can we do better?

Fracture-related infection is a major complication related to musculoskeletal injuries that not only has important clinical consequences, but also a substantial socioeconomic impact. Although fracture-related infection is one of the oldest disease entities known to mankind, it has only recently been defined and, therefore, its global burden is still largely unknown. In this Personal View, we describe the origin of the term fracture-related infection, present the available data on its global impact, and discuss important aspects regarding its prevention and management that could lead to improved outcomes in both high-resource and low-resource settings. We also highlight the need for health-care systems to be adequately compensated for the high cost of human resources (trained staff) and well-equipped facilities required to adequately care for these complex patients. Our aim is to increase awareness among clinicians and policy makers that fracture-related infection is a disease entity that deserves prioritisation in terms of research, with the goal to standardise treatment and improve patient outcomes on a global scale.

Fracture related infection in open tibial fractures

Open tibia fractures frequently occur following high-energy trauma. Contamination of the fracture site combined with limited soft tissue coverage and blood supply means that these open fractures are associated with a high rate of complications, including fracture related infection (FRI). FRI is associated with lowered patient outcomes and requires early recognition and appropriate surgical and medical management. The current evidence on FRI after open tibial fractures largely is limited to case series, small retrospective cohort studies and expert opinion. Recent expert consensus has produced guidelines with the aim of standardising care for these patients. This review summarises the current management strategies employed in treating FRI following open tibial fractures and where possible the evidence behind them.

Enhancing Cranio-Maxillofacial Fracture Care in Low- and Middle-Income Countries: A Systematic Review

Background: Cranio-maxillofacial (CMF) injuries represent a significant challenge in low- and middle-income countries (LMICs), exacerbated by inadequate infrastructure, resources, and training. This systematic review aims to evaluate the current strategies and solutions proposed in the literature to improve CMF fracture care in LMICs, focusing on education, patient transfer, and off-label solutions. Methods: A comprehensive literature search was conducted using PubMed/Medline from January 2000 to June 2023. Studies were selected based on the Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA). Solutions were categorized into three main areas: education (digital and on-site teaching, fellowships abroad), patient transfer to specialized clinics, and off-label/non-operative solutions. Results: Twenty-three articles were included in the review, revealing a consensus on the necessity for enhanced education and training for local surgeons as the cornerstone for sustainable improvements in CMF care in LMICs. Digital platforms and on-site teaching were identified as key methods for delivering educational content. Furthermore, patient transfer to specialized national clinics and innovative off-label techniques were discussed as immediate solutions to provide quality care despite resource constraints. Conclusions: Effective CMF fracture care in LMICs requires a multifaceted approach, prioritizing the education and training of local healthcare professionals, facilitated patient transfer to specialized centers, and the adoption of off-label solutions to leverage available resources. Collaborative efforts between international organizations, local healthcare providers, and educational institutions are essential to implement these solutions effectively and improve patient outcomes in LMICs.

The surgical management of fracture-related infection. Surgical strategy selection and the need for early surgical intervention

The aim of this narrative review is to describe the various surgical management strategies employed in fracture-related infection (FRI), to explore how they are selected and discuss the rationale for early surgical intervention. Surgical treatment options in patients with FRI include debridement, antibiotics and implant retention (DAIR), revision (exchange) or removal. In selecting a treatment strategy, a variety of factors need to be considered, including the condition of the bone, soft tissues, host and causative microorganism. Irrespective of the selected treatment strategy, prompt surgical intervention should be considered in order to confirm the diagnosis of an FRI, to identify the causative organism, remove necrotic or non-viable tissue that can serve as a nidus for ongoing infection, ensure a healthy soft tissue envelope and to prevent the vicious cycle of infection associated with skeletal and/or implant instability. Ultimately, the objective is to prevent the establishment of a persistent infection. Urgent surgery may be indicated in case of active, progressive disease with systemic deterioration, local progression of infection, deterioration of soft tissues, or progressive fracture instability. In case of static disease, the patient should be monitored closely and surgery can be performed on an elective basis, allowing adequate time for optimisation of the host through risk factor modification, optimisation of the soft tissues and careful planning of the surgery.

Diagnostic Performance of a telephone questionnaire for fracture-related infections (FRIs) in open tibia fracture patients in Tanzania

INTRODUCTION

Fracture-related infections (FRIs) are a major cause of trauma-associated morbidity worldwide. In 2018, an expert group supported by the AO Foundation, European Bone and Joint Infection Society developed a consensus definition of FRI. Still, there is limited knowledge on the applicability of this definition in low- and middle-income countries (LMICs). Given the unique barriers that cause low follow-up rates for orthopaedic trauma patients in LMICs, this study aims to evaluate the diagnostic performance of a telephone questionnaire in identifying patients with FRIs after open tibia fracture fixation in Tanzania.

MATERIALS AND METHODS

Patients from a randomized controlled trial investigating the infection prevention benefit of locally applied gentamycin for open tibial fractures were included. Patients completed FRI based telephone questionnaires 7-10 days prior to scheduled follow-ups at 6 weeks, 3 months, 6 months, 9 months, and 1 year. The questionnaire included two "confirmatory" criteria questions for FRI (i.e., open wound and purulent drainage) and three "suggestive" criteria questions (i.e., wound drainage, fever, and warmth). Contingency tests were performed to identify the sensitivity and specificity between answers and adjudicated FRI diagnoses at the corresponding in-person follow-up. Data was analysed using STATA version 15.0 and MedCalc's online diagnostic test calculator.

RESULTS

There were a total of 234 complete questionnaires and 85 unique patients included. The sensitivity and specificity of having any positive answer in the questionnaire was highest at 6 months (100 % and 92.5 %, respectively). For all time-points pooled, sensitivity was 71.4 % and specificity was 93.0 %. Drainage had the highest sensitivity (71.4 %) while fever had the highest specificity (99.6 %). For confirmatory criteria, sensitivity was 14.3 % and specificity was 96.0 %. Contrastingly, the sensitivity for suggestive criteria was higher (71.4 %), with a similar specificity (93.8 %).

CONCLUSION

Our study indicates that telephone questionnaires have adequate diagnostic performance when assessing FRIs. The presence of drainage identified the majority of patients with FRI, and specificities were high across confirmatory and suggestive criteria. Our study is one of the first to evaluate telephone questionnaires as a diagnostic tool for FRIs in patients with open tibia fractures in a LMIC hospital and validates the FRI consensus definition criteria.

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

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

Treatment of fracture-related infection in Latin America (FRILA). Proposal for a multicentre regional registry

Postoperative bone infection is a severe complication in the treatment of fractures. The management of this pathology is challenging, but recent advances have been made to achieve standardization that can help diagnosis and decision-making. However, we are unaware of studies validating these models in Latin America. Therefore, this study aims to collect data from patients with fracture-related infections treated in different institutions in Latin America to create a registry that will assist in future clinical decision-making regarding the diagnostic process and the surgical and medical treatment of these patients.

Predictive factors for fracture-related infection in open tibial fractures in a Sub-Saharan African setting

INTRODUCTION

The management of open tibial fractures (OTF) is challenging in low and middle-income countries (LMICs) where appropriate human resources and infrastructure (including equipment, implants and surgical supplies) are not readily available and medical care is not readily accessible. OTF are not rarely associated with a subsequent fracture-related infection (FRI), which is one of the most devastating and difficult to cure complications in orthopaedic trauma care. The aim of this study was to determine the rate and the predictive factors of FRI in OTF in a limited-resource setting of sub-Saharan Africa.

METHODS

Patients with OTF who underwent surgery from July 2015 to December 2020 and followed-up for at least 12 months in a tertiary care teaching hospital in Yaoundé (Cameroon) were retrospectively investigated. Diagnosis of FRI was based on the confirmatory criteria of the International FRI Consensus definition. All patients with bone infections, occurring at any time point during follow-up, were included. Logistic regression was used to determine the predictive factors for FRI.

RESULTS

One hundred and five patients with OTF were studied. With a mean follow-up period of 29.5 ± 16.6 months, 33 patients (31.4%) presented with FRI. Gustilo-Anderson type of OTF, compliance with antibiotics, blood transfusion, time to first washing of the wounds and method of bone fixation were factors associated with the occurrence of FRI. In multivariable logistic regression, 6-hours delay to first washing of the wounds (OR=8.07, 95% CI: 1.43-45.31, p = 0.01), and compliance with antibiotics (OR=11.33, 95%CI: 1.11-115.6, p = 0.04) were the only independent predictors of FRI.

CONCLUSION

The overall rate of FRI in open tibial fracture is still high in the sub-Saharan African context. For similar low-resources settings, this study supports the recommendations (1) to perform a very early washing-dressing-splinting of OTF on admission of the patient, (2) to administer antibiotics early, and (3) to perform surgery as soon as reasonably possible, once appropriate personnel, equipment, implants and surgical supplies are available.

Dead space management strategies in the treatment of chronic osteomyelitis: a retrospective review

PURPOSE

Dead space management is critically important during the treatment of chronic osteomyelitis. Many dead space management strategies are available, each with their respective advantages and shortcomings. This study aims to present the outcomes and complications of dead space management strategies employed in the treatment of chronic osteomyelitis at a single tertiary level musculoskeletal unit.

METHODS

A retrospective review of dead space management strategies employed at a tertiary-level musculoskeletal infection unit was conducted. Patients of any age treated for chronic osteomyelitis of the appendicular skeleton with a minimum follow-up of 6 months were included in the study. Data were collected regarding patient demographics, aetiology and site of infection, dead space management strategy employed, follow-up period and outcome in terms of resolution of infection.

RESULTS

A final cohort of 132 patients underwent surgical treatment with a dedicated dead space management strategy for chronic osteomyelitis of the appendicular skeleton. Eleven patients (8%) experienced a recurrence of infection. Seven patients (63%) with recurrence were type B hosts, while four patients (37%) were type A hosts.

CONCLUSION

Dead space management is an integral part of treating chronic osteomyelitis; however, no guidelines currently exist regarding the most appropriate strategy. Favourable results are achievable in low to middle-income countries, and it is evident that no dead space management strategy is superior to another. The pursuit for the ideal void filler is ongoing.

LEVEL OF EVIDENCE

III.

Aetiology of long bone chronic osteomyelitis: an analysis of the current situation in one region in Egypt

INTRODUCTION

Chronic osteomyelitis (COM) is a devastating infection requiring a multidisciplinary approach, including radiology, microbiology, pathology, and orthopaedic surgery to treat. The present study analysed the bacterial profile causing chronic osteomyelitis and their antibiogram in our region. PATIENTS AND METHODS: This prospective study was done on a consecutive group of patients who underwent surgical debridement for long bone COM. Three to six deep tissue samples were collected during the index debridement for microbiology and one sample for histopathology. Antimicrobial sensitivity testing used an automated bacterial identification system. Gram stain was used to identify the bacteria type from its size, shape, and arrangement of bacterial growth.

RESULTS

Intra-operative deep tissue and bone specimens accurately identified causative bacteria in 84.8% of patients. Gram-ve bacilli (GNB) were the most common causative organisms in 51.6% of all growing samples (36.4% isolated G-ve and 15.2% mixed with G + ve). Thirty-three patients (30 males/three females) were included; the mean age at index debridement surgery was 37.1 years. Half of the cohort had no metalwork. The aetiology of COM was post-operative infection in half of the patients.

CONCLUSION

There may be concerning features in our patients' aetiologies and causative organisms; closed fractures turn into COM postoperatively, several unsuccessful attempts, delayed index debridement, and more GNB. Plans need to be applied to break the cycle and improve outcomes.

Use of a Novel Anti-Infective Noble Metal Alloy-Coated Titanium Orthopedic Nail in Patients with Open Fractures: A Case Series from Malaysia

Fracture-related infection is a serious complication in orthopedic surgery with severe consequences for the patient. We evaluated whether a novel noble metal nail-coating technology can prevent bacterial adhesion and biofilm formation without interfering with bony union. In this retrospective, single-center case series, we described the incidence of fracture-related infections and bony union achievement in patients who had Gustilo type IIIa or IIIb femoral or tibial fractures treated with noble metal alloy-coated titanium nails. Patients were treated between January 2017 and January 2019 at the Sultanah Aminah Hospital, Johor Bahru, Malaysia. Information on fracture-related infections and bone healing assessments was collected from patient records. Additionally, three independent experts retrospectively reviewed patient X-ray images from follow-up visits to further evaluate bony union achievement. Thirty-five patients were included. Infection developed in 3/35 (8.6%) patients; all cases were resolved by antibiotic therapy. Radiographs were available for 32 patients; these confirmed the presence of bone healing in 30/32 (93.8%) patients. However, according to patient records, bony union was achieved in all patients. No safety issues were recorded. This case series suggests that a noble metal alloy-coated titanium nail can prevent infection and facilitate bony union achievement in patients undergoing surgery for severe open fractures.