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Metsemakers WJ, Moriarty TF, Morgenstern M, Marais L, Onsea J, O'Toole RV, Depypere M, Obremskey WT, Verhofstad MHJ, McNally M, Morshed S, Wouthuyzen-Bakker M, Zalavras C. The global burden of fracture-related infection: can we do better? THE LANCET. INFECTIOUS DISEASES 2024; 24:e386-e393. [PMID: 38042164 DOI: 10.1016/s1473-3099(23)00503-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 12/04/2023]
Abstract
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.
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Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - T Fintan Moriarty
- AO Research Institute Davos, Davos, Switzerland; Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Leonard Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Martin McNally
- The Bone Infection Unit, Oxford University Hospitals, Oxford, UK
| | - Saam Morshed
- Department of Orthopaedic Surgery and Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Marais LC, Zalavras CG, Moriarty FT, Kühl R, Metsemakers WJ, Morgenstern M. The surgical management of fracture-related infection. Surgical strategy selection and the need for early surgical intervention. J Orthop 2024; 50:36-41. [PMID: 38162257 PMCID: PMC10755499 DOI: 10.1016/j.jor.2023.11.033] [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: 06/26/2023] [Accepted: 11/14/2023] [Indexed: 01/03/2024] Open
Abstract
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.
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Affiliation(s)
- Leonard C. Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Charalampos G. Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Fintan T. Moriarty
- AO Research Institute Davos, Davos, Switzerland
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Richard Kühl
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
- Department of Infectious Diseases and Hospital Hygiene, University Hospital Basel, Switzerland
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
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3
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Jennings JA, Arts JJ, Abuhussein E, Alt V, Ashton N, Baertl S, Bhattacharyya S, Cain JD, Dintakurthi Y, Ducheyne P, Duffy H, Falconer R, Gautreaux M, Gianotti S, Hamilton JL, Hylen A, van Hoogstraten S, Libos A, Markovics A, Mdingi V, Montgomery EC, Morgenstern M, Obremskey W, Priddy LB, Tate J, Ren Y, Ricciardi B, Tucker LJ, Weeks J, Vanvelk N, Williams D, Xie C, Hickok N, Schwarz EM, Fintan Moriarty T. 2023 International Consensus Meeting on musculoskeletal infection: Summary from the treatment workgroup and consensus on treatment in preclinical models. J Orthop Res 2024; 42:500-511. [PMID: 38069631 DOI: 10.1002/jor.25765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024]
Abstract
In vitro and in vivo studies are critical for the preclinical efficacy assessment of novel therapies targeting musculoskeletal infections (MSKI). Many preclinical models have been developed and applied as a prelude to evaluating safety and efficacy in human clinical trials. In performing these studies, there is both a requirement for a robust assessment of efficacy, as well as a parallel responsibility to consider the burden on experimental animals used in such studies. Since MSKI is a broad term encompassing infections varying in pathogen, anatomical location, and implants used, there are also a wide range of animal models described modeling these disparate infections. Although some of these variations are required to adequately evaluate specific interventions, there would be enormous value in creating a unified and standardized criteria to animal testing in the treatment of MSKI. The Treatment Workgroup of the 2023 International Consensus Meeting on Musculoskeletal Infection was responsible for questions related to preclinical models for treatment of MSKI. The main objective was to review the literature related to priority questions and estimate consensus opinion after voting. This document presents that process and results for preclinical models related to (1) animal model considerations, (2) outcome measurements, and (3) imaging.
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Affiliation(s)
| | - Jacobus J Arts
- Department of Orthopaedic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
- Department Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Ezzuddin Abuhussein
- Department of Biomedical Engineering, University of Memphis, Memphis, Tennessee, USA
| | - Volker Alt
- Department of Trauma Surgery, University Hospital, Regensburg, Germany
| | - Nicholas Ashton
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - Susanne Baertl
- Department of Trauma Surgery, University Hospital, Regensburg, Germany
| | - Sanjib Bhattacharyya
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- XeroThera Inc., Philadelphia, Pennsylvania
| | - Jarrett D Cain
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yogita Dintakurthi
- Department of Biomedical Engineering, University of Memphis, Memphis, Tennessee, USA
| | - Paul Ducheyne
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hannah Duffy
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - Robert Falconer
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - Malley Gautreaux
- Department of Agricultural and Biological Engineering, Mississippi State University, Mississippi State, Mississippi, USA
| | - Sofia Gianotti
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - John L Hamilton
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Annika Hylen
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - Sanne van Hoogstraten
- Department of Orthopaedic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Andres Libos
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Department of Orthopaedic Surgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Adrienn Markovics
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Emily C Montgomery
- Department of Biomedical Engineering, University of Memphis, Memphis, Tennessee, USA
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - William Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lauren B Priddy
- Department of Agricultural and Biological Engineering, Mississippi State University, Mississippi State, Mississippi, USA
| | - Jermiah Tate
- Department of Biomedical Engineering, University of Memphis, Memphis, Tennessee, USA
| | - Youliang Ren
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
| | - Benjamin Ricciardi
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York, USA
| | - Luke J Tucker
- Department of Agricultural and Biological Engineering, Mississippi State University, Mississippi State, Mississippi, USA
| | - Jason Weeks
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
| | - Niels Vanvelk
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Dustin Williams
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Chao Xie
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
| | - Noreen Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Edward M Schwarz
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
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Tsang STJ, Ferreira N. The role of implant retention and conservative management in the management of fracture-related infection. J Orthop 2024; 48:47-51. [PMID: 38077474 PMCID: PMC10700830 DOI: 10.1016/j.jor.2023.11.040] [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: 06/25/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 08/03/2024] Open
Abstract
UNLABELLED Fracture-related infection (FRI) management has advanced considerably in recent years, offering new possibilities for predictable rates of infection eradication. Debridement, antibiotics, and implant retention (DAIR) procedures have shown promise in the treatment of early FRI. This article provides an overview of the principles and indications of DAIR, including the importance of meticulous debridement and the management of dead space. The outcomes of DAIR are discussed, highlighting the range of fracture union rates reported in the literature. The role of antimicrobial suppression in optimizing host biology and facilitating surgical intervention is also explored. While further research is needed to establish optimal treatment strategies, DAIR offers a valuable treatment approach for FRI when specific criteria are met. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Shao-Ting Jerry Tsang
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
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Hu X, Niemann M, Kienzle A, Braun K, Back DA, Gwinner C, Renz N, Stoeckle U, Trampuz A, Meller S. Evaluating ChatGPT responses to frequently asked patient questions regarding periprosthetic joint infection after total hip and knee arthroplasty. Digit Health 2024; 10:20552076241272620. [PMID: 39130521 PMCID: PMC11311159 DOI: 10.1177/20552076241272620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 07/09/2024] [Indexed: 08/13/2024] Open
Abstract
Background Patients access relevant information concerning their orthopaedic surgery resources through multiple information channels before presenting for clinical treatment. Recently, artificial intelligence (AI)-powered chatbots have become another source of information for patients. The currently developed AI chat technology ChatGPT (OpenAI LP) is an application for such purposes and it has been rapidly gaining popularity, including for patient education. This study sought to evaluate whether ChatGPT can correctly answer frequently asked questions (FAQ) regarding periprosthetic joint infection (PJI). Methods Twelve FAQs about PJI after hip and knee arthroplasty were identified from the websites of fifteen international clinical expert centres. ChatGPT was confronted with these questions and its responses were analysed for their accuracy using an evidence-based approach by a multidisciplinary team. Responses were categorised in four groups: (1) Excellent response that did not require additional improvement; (2) Satisfactory responses that required a small amount of improvement; (3) Satisfactory responses that required moderate improvement; and (4) Unsatisfactory responses that required a large amount of improvement. Results From the analysis of the responses given by the chatbot, no reply received an 'unsatisfactory' rating; one did not require any correction; and the majority of the responses required low (7 out of 12) or moderate (4 out of 12) clarification. Although a few responses required minimal clarification, the chatbot responses were generally unbiased and evidence-based, even when asked controversial questions. Conclusions The AI-chatbot ChatGPT was able to effectively answer the FAQs of patients seeking information around PJI diagnosis and treatment. The given information was also written in a manner that can be assumed to be understandable by patients. The chatbot could be a valuable clinical tool for patient education and understanding around PJI treatment in the future. Further studies should evaluate its use and acceptance by patients with PJI.
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Affiliation(s)
- Xiaojun Hu
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Orthopedics, Seventh People's Hospital of Chongqing, Chongqing, China
| | - Marcel Niemann
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Arne Kienzle
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Karl Braun
- Department of Trauma Surgery, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - David Alexander Back
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Clemens Gwinner
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Nora Renz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulrich Stoeckle
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - 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
| | - Sebastian Meller
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Foster AL, Warren J, Vallmuur K, Jaiprakash A, Crawford R, Tetsworth K, Schuetz MA. A population-based epidemiological and health economic analysis of fracture-related infection. Bone Joint J 2024; 106-B:77-85. [PMID: 38160695 DOI: 10.1302/0301-620x.106b1.bjj-2023-0279.r2] [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] [Indexed: 01/03/2024]
Abstract
Aims The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI). Methods This is a retrospective cohort study of operatively managed orthopaedic trauma patients from 1 January 2007 to 31 December 2016, performed in Queensland, Australia. Record linkage was used to develop a person-centric, population-based dataset incorporating routinely collected administrative, clinical, and health economic information. The FRI group consisted of patients with International Classification of Disease 10th Revision diagnosis codes for deep infection associated with an implanted device within two years following surgery, while all others were deemed not infected. Demographic and clinical variables, as well as healthcare utilization costs, were compared. Results There were 111,402 patients operatively managed for orthopaedic trauma, with 2,775 of these (2.5%) complicated by FRI. The development of FRI had a statistically significant association with older age, male sex, residing in rural/remote areas, Aboriginal or Torres Strait Islander background, lower socioeconomic status, road traffic accident, work-related injuries, open fractures, anatomical region (lower limb, spine, pelvis), high injury severity, requiring soft-tissue coverage, and medical comorbidities (univariate analysis). Patients with FRI had an eight-times longer median inpatient length of stay (24 days vs 3 days), and a 2.8-times higher mean estimated inpatient hospitalization cost (AU$56,565 vs AU$19,773) compared with uninfected patients. The total estimated inpatient cost of the FRI cohort to the healthcare system was AU$156.9 million over the ten-year period. Conclusion The results of this study advocate for improvements in trauma care and infection management, address social determinants of health, and highlight the upside potential to improve prevention and treatment strategies.
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Affiliation(s)
- Andrew L Foster
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Jacelle Warren
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, Faculty of Health, Brisbane, Australia
| | - Kirsten Vallmuur
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, Faculty of Health, Brisbane, Australia
| | - Anjali Jaiprakash
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Ross Crawford
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Kevin Tetsworth
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Michael A Schuetz
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
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Marais LC, Hungerer S, Eckardt H, Zalavras C, Obremskey WT, Ramsden A, McNally MA, Morgenstern M, Metsemakers WJ. Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg 2024; 144:259-268. [PMID: 37921993 PMCID: PMC10774153 DOI: 10.1007/s00402-023-05073-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/11/2023] [Indexed: 11/05/2023]
Abstract
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.
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Affiliation(s)
- Leonard C Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Sven Hungerer
- Department of Joint Surgery and Arthroplasty, Trauma Center Murnau, Murnau Germany and Paracelsus Medical University (PMU) Salzburg, Salzburg, Austria
| | - Henrik Eckardt
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex Ramsden
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
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Azi ML, Valderrama-Molina CO, Carabelli G, Cruz MAA, Bidolegui F, Gómez A, Velarde JE, Pires RE, Xicará JA, Belangero WD, Giordano V. Treatment of fracture-related infection in Latin America (FRILA). Proposal for a multicentre regional registry. Injury 2023; 54 Suppl 6:110898. [PMID: 38143112 DOI: 10.1016/j.injury.2023.110898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/04/2023] [Accepted: 06/12/2023] [Indexed: 12/26/2023]
Abstract
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.
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Affiliation(s)
- Matheus Lemos Azi
- Manoel Victorino Hospital, Secretary of Health for the State of Bahia, Bahia, Brazil.
| | | | - Guido Carabelli
- Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Argentina
| | | | - Fernando Bidolegui
- Orthopaedic Trauma Service, Sirio y Libanes Hospital, Buenos Aires, Argentina
| | - Amparo Gómez
- Hospital Universitario de la Samaritana, Bogota, Colombia
| | | | | | | | - William Dias Belangero
- School of Medical Sciences, University of Campinas, Rua Tessalia Vieira de Camargo 126, Cidade Universitaria, 13083-887, Campinas, Sao Paulo, Brazil
| | - Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil; Clínica São Vicente, Rede D'or São Luiz, Rio de Janeiro, Brazil
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9
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Local administration of vancomycin powder in orthopaedic fracture surgery: current practice and trends. OTA Int 2023; 6:e223. [PMID: 36846524 PMCID: PMC9953039 DOI: 10.1097/oi9.0000000000000223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 07/11/2022] [Accepted: 08/14/2022] [Indexed: 02/23/2023]
Abstract
Objectives Surgical site infections in orthopaedic trauma are a significant problem with meaningful patient and health care system-level consequences. Direct application of antibiotics to the surgical field has many potential benefits in reducing surgical site infections. However, to date, the data regarding the local administration of antibiotics have been mixed. This study reports on the variability of prophylactic vancomycin powder use in orthopaedic trauma cases across 28 centers. Methods Intrawound topical antibiotic powder use was prospectively collected within three multicenter fracture fixation trials. Fracture location, Gustilo classification, recruiting center, and surgeon information were collected. Differences in practice patterns across recruiting center and injury characteristics were tested using chi-square statistic and logistic regression. Additional stratified analyses by recruiting center and individual surgeon were performed. Results A total of 4941 fractures were treated, and vancomycin powder was used in 1547 patients (31%) overall. Local administration of vancomycin powder was more frequent in open fractures 38.8% (738/1901) compared with closed fractures 26.6% (809/3040) (P < 0.001). However, the severity of the open fracture type did not affect the rate at which vancomycin powder was used (P = 0.11). Vancomycin powder use varied substantially across the clinical sites (P < 0.001). At the surgeon level, 75.0% used vancomycin powder in less than one-quarter of their cases. Conclusions Prophylactic intrawound vancomycin powder remains controversial with varied support throughout the literature. This study demonstrates wide variability in its use across institutions, fracture types, and surgeons. This study highlights the opportunity for increased practice standardization for infection prophylaxis interventions. Level of Evidence Prognostic-III.
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10
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Risk of Acute Kidney Injury and Fracture-Related Infection After Antibiotic Prophylaxis With Piperacillin-Tazobactam in Open Fractures. J Orthop Trauma 2023; 37:e73-e79. [PMID: 36001947 DOI: 10.1097/bot.0000000000002473] [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] [Accepted: 08/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the effects of prophylactic piperacillin-tazobactam (PT) on inpatient acute kidney injury (AKI) and fracture-related infection (FRI) in patients with open fractures. SETTING The study was conducted at a Level 1 trauma center. PATIENTS We reviewed 358 Gustilo-Anderson type II and III open fractures at our institution from January 2013 to December 2017. INTERVENTION Administration of PT (the PT group) or antibiotics other than PT (the historical control group) during the first 48 hours of arrival for open fracture antibiotic prophylaxis. MAIN OUTCOME MEASUREMENTS The main outcome measurements were rates of inpatient AKI and FRI within six months after definitive fixation. RESULTS There were 176 patients in the PT group and 182 patients in the historical control group. The PT group had worse American Society of Anesthesiologists class ( P = 0.004) and injury severity scores ( P < 0.001), a higher average number of debridements before closure/coverage ( P = 0.043), and higher rates of gross soil contamination ( P = 0.049) and staged procedures ( P = 0.008) compared with the historical control group.There was no difference in the rate of AKI between the PT and historical control groups (5.7% vs. 2.7%, P = 0.166) nor when stratified by Gustilo-Anderson fracture classification (type II: 5.8% vs. 3.6%, P = 0.702; type III: 5.6% vs. 2.0%, P = 0.283). There was no significant difference in the rate of FRI between the PT and historical control groups (23.6% vs. 19.6%, P = 0.469). CONCLUSION The use of PT in prophylactic antimicrobial treatment in patients with Gustilo-Anderson type II and III open fractures does not increase the rate of AKI or FRI. We believe PT can be used as an effective monotherapy in these patients without an increased risk of renal injury, but future investigations are necessary. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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11
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Lu S, Wang L, Luo W, Wang G, Zhu Z, Liu Y, Gao H, Fu C, Ren J, Zhang Y, Zhang Y. Analysis of the epidemiological status, microbiology, treatment methods and financial burden of hematogenous osteomyelitis based on 259 patients in Northwest China. Front Endocrinol (Lausanne) 2023; 13:1097147. [PMID: 36686458 PMCID: PMC9846127 DOI: 10.3389/fendo.2022.1097147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/12/2022] [Indexed: 01/05/2023] Open
Abstract
Background The incidence of hematogenous osteomyelitis is on the rise, and the prognosis is poor. There has been no large-scale epidemiological analysis of hematogenous osteomyelitis in the world, and the treatment method is still controversial. Methods A retrospective case study method was used to collect and analyze clinical data obtained from patients with hematogenous osteomyelitis in a tertiary hospital in Northwest China from January 1, 2011, to December 31, 2020. The aim of this study was to investigate the epidemiological status, microbiological characteristics, treatment and financial burden of hematogenous osteomyelitis in Northwest China to explore the therapeutic effects of different treatment methods, elucidate the epidemiological characteristics of hematogenous osteomyelitis and to provide a basis for the choice of treatment. Results We included 259 patients with hematogenous osteomyelitis, including 96 patients with acute hematogenous osteomyelitis and 163 patients with chronic hematogenous osteomyelitis. The cause of the disease was not obvious in most patients, the sex ratio of males to females was 1.98, and the three most common infected sites were the tibia, femur and phalanx. Regarding preoperative serum inflammatory markers, the rate of positivity for ESR was the highest at 67.58%. Among pathogenic microorganisms, Staphylococcus aureus was the most common. Regarding the financial burden, the median total cost per patient was 25,754 RMB, and medications accounted for the largest proportion of the main costs. Conclusions The most common pathogen associated with HO infection was MSSA. Oxacillin has good PK and PD and is recommended as the first-line drug. Some blood-borne bone infections may lead to complications, such as pulmonary infection through bacteremia, which requires early detection to avoid a missed diagnosis. Regarding surgical intervention, debridement plus absorbable calcium sulfate bone cement and calcium sulfate calcium phosphate bone cement exclusion have achieved good therapeutic effects, but they are worthy of further in-depth research. Regarding the financial burden, the median total cost per patient was 25,754 RMB. The financial burden of blood-borne osteomyelitis was lower than that of traumatic osteomyelitis. Among the main costs, drugs accounted for the largest proportion.
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Affiliation(s)
- Shuaikun Lu
- Department of Orthopaedics, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Linhu Wang
- Department of Orthopaedics, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Wen Luo
- Department of Ultrasound, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Guoliang Wang
- Department of Orthopaedics, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Zhenfeng Zhu
- Department of Orthopaedics, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Yunyan Liu
- Department of Orthopaedics, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Hao Gao
- Department of Orthopaedics, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Congxiao Fu
- Department of Orthopaedics, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Jun Ren
- Department of Orthopaedics, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Yunfei Zhang
- Department of Orthopaedics, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Yong Zhang
- Department of Orthopaedics, Tangdu Hospital, Air Force Medical University, Xi’an, China
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12
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Physical Approaches to Prevent and Treat Bacterial Biofilm. Antibiotics (Basel) 2022; 12:antibiotics12010054. [PMID: 36671255 PMCID: PMC9854850 DOI: 10.3390/antibiotics12010054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/11/2022] [Accepted: 12/20/2022] [Indexed: 12/30/2022] Open
Abstract
Prosthetic joint infection (PJI) presents several clinical challenges. This is in large part due to the formation of biofilm which can make infection eradication exceedingly difficult. Following an extensive literature search, this review surveys a variety of non-pharmacological methods of preventing and/or treating biofilm within the body and how they could be utilized in the treatment of PJI. Special attention has been paid to physical strategies such as heat, light, sound, and electromagnetic energy, and their uses in biofilm treatment. Though these methods are still under study, they offer a potential means to reduce the morbidity and financial burden related to multiple stage revisions and prolonged systemic antibiotic courses that make up the current gold standard in PJI treatment. Given that these options are still in the early stages of development and offer their own strengths and weaknesses, this review offers an assessment of each method, the progress made on each, and allows for comparison of methods with discussion of future challenges to their implementation in a clinical setting.
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13
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Saltiel G, Meyssonnier V, Kerroumi Y, Heym B, Lidove O, Marmor S, Zeller V. Cutibacterium acnes Prosthetic Joint Infections: Is Rifampicin-Combination Therapy Beneficial? Antibiotics (Basel) 2022; 11:antibiotics11121801. [PMID: 36551458 PMCID: PMC9774273 DOI: 10.3390/antibiotics11121801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/26/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
No consensus has been reached on the optimal antibiotic regimen to treat Cutibacterium acnes PJIs (Ca-PJIs). In vitro studies showed excellent rifampicin efficacy against biofilm-associated C. acnes infections, but clinical studies did not confirm the superiority of rifampicin-combined therapy over monotherapy. This prospective cohort study was undertaken to analyze the outcomes of 70 patients who underwent exchange arthroplasty for chronic monomicrobial Ca-PJI and were treated with rifampicin or without between 2004 and 2019. The 37 patients treated from January 2004 to August 2014 were prescribed rifampicin-combination therapy and the 33 treated from September 2014 to December 2019 received monotherapy without rifampicin. The primary endpoint was the 2-year Kaplan-Meier-estimated reinfection-free probability, including relapses and new-pathogen PJIs. The 2-year reinfection-free rate was high and not different for patients who had received rifampicin or not (89.2% vs. 93.8%, respectively; p = 0.524). None of the patients relapsed and six developed new-pathogen PJIs. Our results do not support a benefit of rifampicin-combination therapy for patients who underwent exchange arthroplasty for chronic Ca-PJIs.
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Affiliation(s)
- Grégoire Saltiel
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
- Service de Médecine Interne et Infectiologie, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
| | - Vanina Meyssonnier
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
- Service de Médecine Interne et Infectiologie, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
| | - Younes Kerroumi
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
| | - Beate Heym
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
- Laboratoire des Centres de Santé et Hôpitaux d’Île-de-France, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
| | - Olivier Lidove
- Service de Médecine Interne et Infectiologie, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
| | - Simon Marmor
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
| | - Valérie Zeller
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
- Service de Médecine Interne et Infectiologie, Groupe Hospitalier Diaconesses–Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France
- Correspondence: ; Tel.: +33-1-44-64-17-80
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14
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Corona PS, Carbonell-Rosell C, Vicente M, Serracanta J, Tetsworth K, Glatt V. Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect. Arch Orthop Trauma Surg 2022; 142:3877-3887. [PMID: 34936017 PMCID: PMC9596551 DOI: 10.1007/s00402-021-04299-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 12/01/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Managing critical-sized tibial defects is one of the most complex challenges orthopedic surgeons face. This is even more problematic in the presence of infection and soft-tissue loss. The purpose of this study is to describe a comprehensive three-stage surgical protocol for the reconstruction of infected tibial injuries with combined bone defects and soft-tissue loss, and report the clinical outcomes. MATERIALS AND METHODS A retrospective study at a specialized limb reconstruction center identified all patients with infected tibial injuries with bone and soft-tissue loss from 2010 through 2018. Thirty-one patients were included. All cases were treated using a three-stage protocol: (1) infected limb damage control; (2) soft-tissue coverage with a vascularized or local flap; (3) definitive bone reconstruction using distraction osteogenesis principles with external fixation. PRIMARY OUTCOMES limb salvage rate and infection eradication. SECONDARY OUTCOMES patient functional outcomes and satisfaction. RESULTS Patients in this series of chronically infected tibias had been operated upon 3.4 times on average before starting our limb salvage protocol. The mean soft-tissue and bone defect sizes were 124 cm2 (6-600) and 5.4 cm (1-23), respectively. A free flap was performed in 67.7% (21/31) of the cases; bone transport was the selected bone-reconstructive option in 51.7% (15/31). Local flap failure rate was 30% (3/10), with 9.5% for free flaps (2/21). Limb salvage rate was 93.5% (29/31), with infection eradicated in all salvaged limbs. ASAMI bone score: 100% good/excellent. Mean VAS score was 1.0, and ASAMI functional score was good/excellent in 86% of cases. Return-to-work rate was 83%; 86% were "very satisfied" with the treatment outcome. CONCLUSION A three-stage surgical approach to treat chronically infected tibial injuries with combined bone and soft-tissue defects yields high rates of infection eradication and successful limb salvage, with favorable functional outcomes and patient satisfaction.
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Affiliation(s)
- Pablo S Corona
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carla Carbonell-Rosell
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Matías Vicente
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Serracanta
- Department of Plastic Surgery and Major Burn, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Orthopaedic Research Centre of Australia, Brisbane, Australia
| | - Vaida Glatt
- Orthopaedic Research Centre of Australia, Brisbane, Australia
- Department of Orthopaedic Surgery, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
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15
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McNally M, Corrigan R, Sliepen J, Dudareva M, Rentenaar R, IJpma F, Atkins BL, Wouthuyzen-Bakker M, Govaert G. What Factors Affect Outcome in the Treatment of Fracture-Related Infection? Antibiotics (Basel) 2022; 11:antibiotics11070946. [PMID: 35884200 PMCID: PMC9312092 DOI: 10.3390/antibiotics11070946] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 12/24/2022] Open
Abstract
This international, multi-center study investigated the effect of individual components of surgery on the clinical outcomes of patients treated for fracture-related infection (FRI). All patients with surgically treated FRIs, confirmed by the FRI consensus definition, were included. Data were collected on demographics, time from injury to FRI surgery, soft tissue reconstruction, stabilization and systemic and local anti-microbial therapy. Patients were followed up for a minimum of one year. In total, 433 patients were treated with a mean age of 49.7 years (17−84). The mean follow-up time was 26 months (range 12−72). The eradication of infection was successful in 86.4% of all cases and 86.0% of unhealed infected fractures were healed at the final review. In total, 3.3% required amputation. The outcome was not dependent on age, BMI, the presence of metalwork or time from injury (recurrence rate 16.5% in FRI treated at 1−10 weeks after injury; 13.1% at 11−52 weeks; 12.1% at >52 weeks: p = 0.52). The debridement and retention of a stable implant (DAIR) had a failure rate of 21.4%; implant exchange to a new internal fixation had a failure rate of 12.5%; and conversion to external fixation had a failure rate of 10.3% (adjusted hazard ratio (aHR) DAIR vs. Ext Fix 2.377; 95% C.I. 0.96−5.731). Tibial FRI treated with a free flap was successful in 92.1% of cases and in 80.4% of cases without a free flap (HR 0.38; 95% C.I. 0.14−1.0), while the use of NPWT was associated with higher recurrence rates (HR 3.473; 95% C.I. 1.852−6.512). The implantation of local antibiotics reduced the recurrence from 18.7% to 10.0% (HR 0.48; 95% C.I. 0.29−0.81). The successful treatment of FRI was multi-factorial. These data suggested that treatment decisions should not be based on time from injury alone, as other factors also affected the outcome. Further work to determine the best indications for DAIR, free flap reconstruction and local antibiotics is warranted.
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Affiliation(s)
- Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
- Correspondence:
| | - Ruth Corrigan
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
- Nuffield Department of Clinical Laboratory Sciences, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands; (J.S.); (F.I.)
| | - Maria Dudareva
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
| | - Rob Rentenaar
- Department of Medical Microbiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Frank IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands; (J.S.); (F.I.)
| | - Bridget L. Atkins
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands;
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands;
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16
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Masters EA, Ricciardi BF, Bentley KLDM, Moriarty TF, Schwarz EM, Muthukrishnan G. Skeletal infections: microbial pathogenesis, immunity and clinical management. Nat Rev Microbiol 2022; 20:385-400. [PMID: 35169289 PMCID: PMC8852989 DOI: 10.1038/s41579-022-00686-0] [Citation(s) in RCA: 167] [Impact Index Per Article: 83.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 12/13/2022]
Abstract
Osteomyelitis remains one of the greatest risks in orthopaedic surgery. Although many organisms are linked to skeletal infections, Staphylococcus aureus remains the most prevalent and devastating causative pathogen. Important discoveries have uncovered novel mechanisms of S. aureus pathogenesis and persistence within bone tissue, including implant-associated biofilms, abscesses and invasion of the osteocyte lacuno-canalicular network. However, little clinical progress has been made in the prevention and eradication of skeletal infection as treatment algorithms and outcomes have only incrementally changed over the past half century. In this Review, we discuss the mechanisms of persistence and immune evasion in S. aureus infection of the skeletal system as well as features of other osteomyelitis-causing pathogens in implant-associated and native bone infections. We also describe how the host fails to eradicate bacterial bone infections, and how this new information may lead to the development of novel interventions. Finally, we discuss the clinical management of skeletal infection, including osteomyelitis classification and strategies to treat skeletal infections with emerging technologies that could translate to the clinic in the future.
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Affiliation(s)
- Elysia A Masters
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA
| | - Benjamin F Ricciardi
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Karen L de Mesy Bentley
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA.
| | - Gowrishankar Muthukrishnan
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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17
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Kvarda P, Puelacher C, Clauss M, Kuehl R, Gerhard H, Mueller C, Morgenstern M. Perioperative myocardial injury and mortality after revision surgery for orthopaedic device-related infection. Bone Joint J 2022; 104-B:696-702. [PMID: 35638215 DOI: 10.1302/0301-620x.104b6.bjj-2021-1486.r1] [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] [Indexed: 11/05/2022]
Abstract
AIMS Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort. METHODS We prospectively included consecutive patients at high cardiovascular risk (defined as age ≥ 45 years with pre-existing coronary, peripheral, or cerebrovascular artery disease, or any patient aged ≥ 65 years, plus a postoperative hospital stay of > 24 hours) undergoing septic or aseptic major orthopaedic surgery between July 2014 and October 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T. All-cause mortality was assessed at one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery for PJI or FRI, and patients receiving aseptic major bone and joint surgery. RESULTS In total, 911 consecutive patients were included. The overall perioperative myocardial injury (PMI) rate was 15.4% (n = 140). Septic revision surgery for PJI was associated with a significantly higher PMI rate (43.8% (14/32) vs 14.5% (57/393); p = 0.001) and one-year mortality rate (18.6% (6/32) vs 7.4% (29/393); p = 0.038) compared to aseptic revision or primary arthroplasty. The association with PMI persisted in multivariable analysis with an adjusted odds ratio (aOR) of 4.7 (95% confidence interval (CI) 2.1 to 10.7; p < 0.001), but was not statistically significant for one-year mortality (aOR 1.9 (95% CI 0.7 to 5.4; p = 0.240). PMI rate (15.2% (5/33) vs 14.1% (64/453)) and one-year mortality (15.2% (5/33) vs 9.1% (41/453)) after FRI revision surgery were comparable to aseptic long-bone fracture surgery. CONCLUSION Patients undergoing revision surgery for PJI were at a risk of PMI and death compared to those undergoing aseptic arthroplasty surgery. Screening for PMI and treatment in specialized multidisciplinary units should be considered in major bone and joint infections. Cite this article: Bone Joint J 2022;104-B(6):696-702.
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Affiliation(s)
- Peter Kvarda
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Christian Puelacher
- University of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Richard Kuehl
- University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Hatice Gerhard
- University of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Christian Mueller
- University of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
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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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Declercq P, Zalavras C, Mertens B, Van der Linden L, Nijs S, Spriet I, Metsemakers WJ. Perioperative antibiotic prophylaxis in long bone open fractures: the need for randomized controlled trials. Arch Orthop Trauma Surg 2022; 142:1063-1064. [PMID: 33512582 DOI: 10.1007/s00402-021-03796-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/12/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Peter Declercq
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, University of Leuven, Leuven, Belgium
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Beatrijs Mertens
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, University of Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, University of Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.
- Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium.
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20
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Zhu Y, Chen W, Qin S, Zhang Q, Zhang Y. Surgeon volume and risk of deep surgical site infection following open reduction and internal fixation of closed ankle fracture. Int Wound J 2022; 19:2136-2145. [PMID: 35641242 DOI: 10.1111/iwj.13819] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/14/2022] [Accepted: 04/07/2022] [Indexed: 11/29/2022] Open
Abstract
Increasing evidences have shown that surgeon volume was associated with postoperative complications or outcomes in a variety of orthopaedics surgeries, but few were focused on ankle fractures. This study aimed to investigate the deep surgical site infection (DSSI) in association with the surgeon volume following open reduction and internal fixation (ORIF) of ankle fractures. This was a retrospective analysis of the prospectively collected data on patients who underwent ORIF for acute closed ankle fractures between October 2014 and June 2020. Surgeon volume was defined as the number of ORIF procedures performed within 12 months preceding the index operation. The receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off value, whereby surgeon volume was dichotomized as high or low. The outcome was DSSI within 1 year postoperatively. Multivariate logistics analysis was performed to examine the DSSI in association with surgeon volume and multiple sensitivity/subgroup analyses were performed to refine the findings. Among 1562 patients, 33 (2.1%) developed a DSSI. The optimal cut-off value was 7/year. Low-volume (<7/year) was significantly associated with a 5.0-fold increased risk of DSSI (95%CI, 2.2-11.3; P < .001). Sensitivity/subgroup analyses restricted to patients aged <65 years, with or without concurrent fractures, with unimalleolar fractures, bi- or trimalleolar fractures, receiving ORIF within 14 days and those operated by ≥10-year experience surgeons showed the consistently significant results (ORs, 2.7-6.8, all P < .05). The surgeon volume of <7 cases/year is associated with an increased risk of DSSI. It is more feasible that patients with complex fractures or conditions (eg, bi- and trimalleolar or presence of concurrent fractures) are preferentially directed to high-volume and experienced surgeons.
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Affiliation(s)
- Yanbin Zhu
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, China
| | - Wei Chen
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, China
| | - Shiji Qin
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, China
| | - Qi Zhang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, China.,Chinese Academy of Engineering, Beijing, China
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21
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Conway JD, Elhessy AH, Galiboglu S, Patel N, Gesheff MG. Efficacy of Infection Eradication in Antibiotic Cement-Coated Intramedullary Nails for Fracture-Related Infections, Nonunions, and Fusions. Antibiotics (Basel) 2022; 11:antibiotics11060709. [PMID: 35740117 PMCID: PMC9219703 DOI: 10.3390/antibiotics11060709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 02/01/2023] Open
Abstract
Antibiotic cement-coated intramedullary nails (ACCINs) are increasing in popularity as a viable solution for the treatment of fracture-related infections (FRIs), infected long bone nonunions, and arthrodeses without an external fixator. ACCINs effectively manage to fulfill three of the basic principles for eradicating osteomyelitis: dead space management, antibiotic delivery, and bone stability. We performed a retrospective review of 111 patients who were treated with ACCINs between January 2014 and December 2020. In our series, 87.4% (n = 97) of patients achieved healed and uninfected bone or stable arthrodesis at a mean follow-up of 29.2 months (range, 6–93 months). Additionally, 69.1% (n = 67) of healed patients were resolved after only one procedure, and the remainder (30.9%, n = 30) healed after one or more additional procedures. The mean number of additional procedures was 2.1 (range, 1–6 additional procedures). The overall limb salvage rate was 93.7% (n = 104). The majority of the total cohort were successfully treated in only one surgery. This study suggests that ACCINs are effective in the treatment of FRIs, infected long bone nonunions, and infected ankle and knee arthrodeses.
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22
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Vanvelk N, Chen B, Van Lieshout EMM, Zalavras C, Moriarty TF, Obremskey WT, Verhofstad MHJ, Metsemakers WJ. Duration of Perioperative Antibiotic Prophylaxis in Open Fractures: A Systematic Review and Critical Appraisal. Antibiotics (Basel) 2022; 11:293. [PMID: 35326757 PMCID: PMC8944527 DOI: 10.3390/antibiotics11030293] [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] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 02/05/2023] Open
Abstract
Fracture-related infection (FRI) remains a serious complication in open fracture care. Adequate surgical treatment and perioperative antibiotic prophylaxis (PAP) are key factors influencing the outcome. However, data concerning the optimal duration of PAP is scarce. The aim of this systematic review was to provide an overview of current evidence on the association between PAP duration and FRI in open fractures. A comprehensive search on 13 January 2022, in Embase, Medline, Cochrane, Web of Science and Google Scholar revealed six articles. Most studies compared either 1 day versus 5 days of PAP or included a cut-off at 72 h. Although prolonged PAP was not beneficial in the majority of patients, the variety of antibiotic regimens, short follow-up periods and unclear description of outcome parameters were important limitations that were encountered in most studies. This systematic review demonstrates a lack of well-constructed studies investigating the effect of PAP duration on FRI. Based on the available studies, prolonged PAP does not appear to be beneficial in the prevention of FRI in open fractures. However, these results should be interpreted with caution since all included studies had limitations. Future randomized trials are necessary to answer this research question definitively.
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Affiliation(s)
- Niels Vanvelk
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (N.V.); (E.M.M.V.L.); (M.H.J.V.)
| | - Baixing Chen
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Development and Regeneration, KU Leuven—University of Leuven, 3000 Leuven, Belgium
| | - Esther M. M. Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (N.V.); (E.M.M.V.L.); (M.H.J.V.)
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA;
| | | | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Michael H. J. Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (N.V.); (E.M.M.V.L.); (M.H.J.V.)
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Development and Regeneration, KU Leuven—University of Leuven, 3000 Leuven, Belgium
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Peng C, Liu K, Tian Q, Tusunniyazi M, Kong W, Luan H, Liu X, Zhao Y. Evaluation of complications associated with bifocal bone transport as treatment for either proximal, intermediate or distal femoral defects caused by infection: outcome analysis of 76 patients. BMC Musculoskelet Disord 2022; 23:132. [PMID: 35139849 PMCID: PMC8829987 DOI: 10.1186/s12891-022-05078-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the outcomes of bifocal bone transport in the treatment of femoral bone defects caused by infections. METHODS Clinical and radiographic data of patients with infected femoral nonunion treated by the bifocal bone transport at our hospital were analyzed retrospectively, from January 2008 to December 2019. Depending on the location of bone defects, the patients were divided into three groups (proximal, intermediate, and distal). The Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria was applied to assess the bone and functional outcomes. Postoperative complications of three groups were documented and compared. RESULTS Seventy-six cases of infected femoral bone defects (31 cases of proximal, 19 cases of intermediate, and 26 cases of distal) were managed by bifocal bone transport successfully with a mean follow-up time of 30.8 months (range, 23 to 41 months). There were 58 men (76.3%) and 18 women (23.6%), with a mean age of 38.8 years (range, 23 to 60 years). The bone union was received in 76 cases with a mean of 6.9 months (range, 5 to 8 months). Pin tract infection was observed in twenty-nine cases (38.1%), 7 cases (9.2%) of muscle contractures, 3 cases (7.9%) of joint stiffness, 13 cases (17.1%) of axial deviation, 2 cases (2.6%) of delayed union, one case (1.3%) of nonunion, and none (0%) of transport gap re-fracture. One patient (1.3%) was scheduled for knee arthroplasty when bone transport treatment ended. CONCLUSIONS Bone transport using an external rail fixator was a practical method to treat the femoral bone defects, since the satisfactory rate of bone union and limb function recovery. Complications of distal femoral bone transport were more severe than the proximal and intermedia, but the rate of complication was the least of the three groups. Soft-tissue-related complications were more likely to occur in the intermediate bone transport.
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Affiliation(s)
- Cong Peng
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Kai Liu
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | | | - Maimaitiaili Tusunniyazi
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Weiqi Kong
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Haopeng Luan
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Xiaokang Liu
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Yan Zhao
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
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Azi ML, Kojima KE, Pesántez R, Carabelli G, Borens O, McFadyen I, Valderrama-Molina CO. Effectiveness of an Online Course on Fracture-Related Infections. J Eur CME 2022; 11:2024682. [PMID: 35036049 PMCID: PMC8757612 DOI: 10.1080/21614083.2021.2024682] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study aims to evaluate the effectiveness of an online course to enable orthopaedic surgeons to acquire the core competencies necessary to prevent and treat fracture-related infections (FRI). This study included orthopaedic surgeons and residents from Latin American countries who attended an online course focused on FRI. The online course included: didactic lectures, small-group clinical case discussions, and panel case discussions. The course was delivered using Zoom® platform and designed to address four core competencies: prevention, definition and diagnosis, antimicrobial therapy, and surgical treatment. An online questionnaire was created distributing 16 questions through six clinical scenarios. Participants were invited to answer the questionnaire before and after the course. Sixty of the 78 course participants answered the pre-course, and 42 the post-course assessment. Relative to before the course, the mean post-course assessment score rose significantly for prevention of FRI (4.1 before and 4.5 after; p = 0.014), definition and diagnosis (2.4 before and 3.4 after; p = 0.001), and surgical treatment (2.2 before and 2.8 after; p = 0.011). The final score encompassing all four core competencies also rose significantly (2.7 before and 3.3 after; p = 0.001). The online course on FRI was feasible and effective, significantly increasing course users’ knowledge of overall competency in managing FRI.
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Affiliation(s)
- Matheus Lemos Azi
- Department of Orthopedics, Manoel Victorino Hospital, Secretary of Health for the State of Bahia, Salvador, Brazil
| | - Kodi Edson Kojima
- Department of Orthopedics and Traumatology, Hospital Das Clinicas Hcfmusp, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Rodrigo Pesántez
- Department of Orthopedics and Traumatology, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Guido Carabelli
- Instituto de Ortopedia Y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Argentina
| | - Olivier Borens
- Septic Surgical Unit, Orthopaedic and Trauma Service, University Hospital Lausanne Chuv, University of Lausanne, Lausanne, Switzerland
| | - Iain McFadyen
- Department of Orthopaedic Surgery, University Hospitals of North Midlands, Stoke-on-Trent, UK
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25
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Eardley W, Ferguson D, Dixon J. Do pin site cleaning techniques and solutions affect pin site infection rate in external fixation? A systematic review of randomized and nonrandomized trials. JOURNAL OF LIMB LENGTHENING & RECONSTRUCTION 2022. [DOI: 10.4103/jllr.jllr_9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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26
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Jennison T, Arveladze S, Moriarty F. The influence of pin material and coatings on the incidence of pin site infection after external fixation. JOURNAL OF LIMB LENGTHENING & RECONSTRUCTION 2022. [DOI: 10.4103/jllr.jllr_35_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Zalavras CG, Aerden L, Declercq P, Belmans A, Metsemakers WJ. Ninety-Day Follow-up Is Inadequate for Diagnosis of Fracture-related Infections in Patients with Open Fractures. Clin Orthop Relat Res 2022; 480:139-146. [PMID: 34351311 PMCID: PMC8673965 DOI: 10.1097/corr.0000000000001911] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/02/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Fracture-related infection (FRI) is a challenging complication in musculoskeletal trauma surgery and often complicates the management of open fractures. The CDC currently advocates a surveillance period of 90 days after fracture fixation, but it is unclear what duration of follow-up constitutes adequate surveillance for FRI. Inadequate follow-up will underestimate infections and, in clinical research, will make any interventions studied appear better than they really are, thereby resulting in misleading conclusions. QUESTIONS/PURPOSES (1) What is the timing of FRI onset in patients with open fractures? (2) What is the proportion of FRIs captured when follow-up is limited to 90 days postoperatively versus when follow-up is extended to 1 year? METHODS This is a secondary analysis of patient data from a previous retrospective cohort study that investigated whether the duration of perioperative antibiotic prophylaxis was independently associated with FRI in patients with open fractures. Of the 530 eligible patients in the source study, 3% (14) died. Of the remaining 516 patients, 97% (502) patients with 559 long-bone open fractures had 2 years of follow-up constituted the base cohort. Forty-seven fractures in 46 patients were complicated by FRI and were the focus of this secondary analysis. Medical records were reviewed in detail specifically for the current study. Seventy-eight percent (36 of 46) of patients were male, and the mean ± SD age was 42 ± 16 years. The most common mechanism of injury was a motor vehicle accident (63% [29 of 46] of patients), and the tibia was the most involved site (53% [25 of 47] of fractures). The median (interquartile range) time to debridement was 3.0 hours (IQR 2.0 to 4.0). FRIs developed in 3% (7 of 247) of Type I open fractures, 7% (11 of 164) of Type II, 17% (18 of 107) of Type IIIA, 29% (9 of 31) of Type IIIB, and 20% (2 of 10) of Type IIIC open fractures. Each clinic visit of each patient was reviewed, and data about the time of onset of any symptoms and signs suggesting or confirming an FRI, as reported by patients and/or determined by treating surgeons, were recorded. The proportions of FRIs with onset by specific time periods were determined. A Kaplan-Meier survival analysis was performed, and the FRI event rates with 95% confidence intervals were calculated. RESULTS The median (IQR) time to the onset of FRI was 52 days (IQR 15 to 153). Follow-up of 90 days captured only 64% (30 of 47) of FRIs, whereas follow-up of 1 year captured 89% (42 of 47) of FRIs. The proportion of FRIs with onset within 1 year increased to 95% (42 of 44) in the presence of an already healed fracture. CONCLUSION Follow-up of 90 days after the management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes. Clinical research on interventions would report results appearing to be much better than they really are, potentially resulting in misleading conclusions. Follow-up of 1 year is preferable because most FRIs will develop before that time, especially when fracture union has occurred. A small percentage of patients may still develop infections beyond the first year after the management of an open fracture. The risk of missing these infections by not extending follow-up beyond 1 year must be balanced against the additional logistical burden. Future prospective multicenter studies and registries with long-term patient follow-up would help clarify this issue.Level of Evidence Level III, diagnostic study.
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Affiliation(s)
- Charalampos G. Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Laurens Aerden
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Declercq
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- KU Leuven – Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Ann Belmans
- KU Leuven – University of Leuven & Universiteit Hasselt, I-BioStat, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven – Department of Development and Regeneration, University of Leuven, Leuven, Belgium
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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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Sun Y, Liu X, Zhu Y, Han Y, Shen J, Bao B, Gao T, Lin J, Huang T, Xu J, Chai Y, Zheng X. Tunable and Controlled Release of Cobalt Ions from Metal-Organic Framework Hydrogel Nanocomposites Enhances Bone Regeneration. ACS APPLIED MATERIALS & INTERFACES 2021; 13:59051-59066. [PMID: 34846853 DOI: 10.1021/acsami.1c16300] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Cobalt (Co) ions, which can mimic hypoxia to promote angiogenesis, exhibit great potential for bone repair. However, a key point for the use of Co ions is that their release profile should be controllable and, more importantly, suitable for the bone regeneration process. Here, 2-ethylimidazole (eIm) was introduced into zeolitic imidazolate framework-67 (ZIF-67) to slow down Co-ion release and fabricate eIm-doped ZIF-67 (eIm/ZIF-67), which was combined into gelatin methacrylate (GelMA) to obtain an in situ photo-cross-linking nanocomposite hydrogel as a tunable Co-ion controlled release system. A tunable and controlled release of Co ions from the nanocomposite hydrogel was achieved by variation of linker composition, and GelMA with 75% eIm/ZIF-67 (with 75% eIm in the precursor solutions) could maintain a 21-day sustained release of Co ions, which is matched with early-stage angiogenesis during the bone formation process. Our in vitro study also showed that the GelMA@eIm/ZIF-67 hydrogel could reduce cytotoxicity and effectively promote the angiogenic activity of human umbilical vein endothelial cells (HUVECs) and osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs). Moreover, an in vivo rat calvarial defect model demonstrated that the GelMA@eIm/ZIF-67 hydrogel exhibited remarkably enhanced bone formation and neovascularization abilities and had good biocompatibility as shown in organ histopathological examinations. Therefore, this novel nanocomposite hydrogel has strong therapeutic potential as a desirable Co-ion controlled release system and a powerful proangiogenic/osteogenic agent for the treatment of bone defects.
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Affiliation(s)
- Yi Sun
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
| | - Xuanzhe Liu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
| | - Yu Zhu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
| | - Yue Han
- School of Chemistry and Molecular Engineering, East China University of Science and Technology, Meilong Road 130, Shanghai 200237, P. R. China
| | - Junjie Shen
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
| | - Bingbo Bao
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
| | - Tao Gao
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
| | - Junqing Lin
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
| | - Tengli Huang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
| | - Jia Xu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
| | - Yimin Chai
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
| | - Xianyou Zheng
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, P. R. China
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Müller SLC, Morgenstern M, Kuehl R, Muri T, Kalbermatten DF, Clauss M, Schaefer DJ, Sendi P, Osinga R. Soft-tissue reconstruction in lower-leg fracture-related infections: An orthoplastic outcome and risk factor analysis. Injury 2021; 52:3489-3497. [PMID: 34304885 DOI: 10.1016/j.injury.2021.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 02/02/2023]
Abstract
Introduction Fracture-related infection (FRI) is a severe post-traumatic complication which is occasionally accompanied by a deficient or even avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative as a vital and intact soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of this study was, to analyse if soft-tissue reconstruction (STR) without complications is associated with a better long-term outcome compared to FRI patients with STR complications. In particular, it was investigated if primary flap failure represented a risk factor for compromised fracture union and recurrence of infection. Patients and Methods Patients with a lower leg FRI requiring STR (local, pedicled and free flaps) who were treated from 2010-18 at the University Hospital Basel were included in this retrospective analysis. The main outcome measure was the success rate of STR, further outcome measures were fracture nonunion and recurrence of infection. Results Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR (muscle flaps: n = 38, fascio-cutaneous flaps: n=19; composite osteo-cutaneous flap: n = 1). In total seven patients required secondary STR due to primary flap failure. All failures and flap-related complications occurred within the first three weeks after surgery. Secondary STR was successful in all cases. A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p = 0.011). Out of the 43 patients who completed the 9-month follow-up, 11 patients presented with fracture nonunion and 12 patients with a recurrent infection. Polymicrobial infection was a significant risk factor for fracture nonunion (p = 0.002). Primary flap failure was neither a risk factor for compromised fracture consolidation (p = 0.590) nor for recurrence of infection (p = 0.508). Conclusion: A considerable number of patients with lower-leg FRI required STR. This patient subgroup is complex and rich in complications and the long-term composite outcome demonstrated a high rate of compromised fracture consolidation and recurrent infections. It appears that secondary STR should be performed, as primary flap failure was neither a risk factor for compromised fracture consolidation nor for recurrence of infection. We propose to monitor these patients closely for three weeks after STR.
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Affiliation(s)
- Seraina L C Müller
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland.
| | - Richard Kuehl
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland
| | - Thaddaeus Muri
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Dirk J Schaefer
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Parham Sendi
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland; Institute for Infectious Diseases, University of Bern, Switzerland
| | - Rik Osinga
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
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Alt V, Giannoudis PV. Musculoskeletal infections: A call for papers to continue the battle against this devastating global challenge. Injury 2021; 52:3187-3188. [PMID: 34740386 DOI: 10.1016/j.injury.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Volker Alt
- Director and Chairman, Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany.
| | - Peter V Giannoudis
- Professor-Section Head, Trauma & Orthopaedic Surgery, School of Medicine, University of Leeds, UK
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Haidari S, IJpma FFA, Metsemakers WJ, Maarse W, Vogely HC, Ramsden AJ, McNally MA, Govaert GAM. The Role of Negative-Pressure Wound Therapy in Patients with Fracture-Related Infection: A Systematic Review and Critical Appraisal. BIOMED RESEARCH INTERNATIONAL 2021; 2021:7742227. [PMID: 34722772 PMCID: PMC8548908 DOI: 10.1155/2021/7742227] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/07/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Fracture-related infection (FRI) is a severe musculoskeletal complication in orthopedic trauma surgery, causing challenges in bony and soft tissue management. Currently, negative-pressure wound therapy (NPWT) is often used as temporary coverage for traumatic and surgical wounds, also in cases of FRI. However, controversy exists about the impact of NPWT on the outcome in FRI, specifically on infection recurrence. Therefore, this systematic review qualitatively assesses the literature on the role of NPWT in the management of FRI. METHODS A literature search of the PubMed, Embase, and Web of Science database was performed. Studies that reported on infection recurrence related to FRI management combined with NPWT were eligible for inclusion. Quality assessment was done using the PRISMA statement and the Newcastle-Ottawa Quality Assessment Scale. RESULTS After screening and quality assessment of 775 unique identified records, eight articles could be included for qualitative synthesis. All eight studies reported on infection recurrence, which ranged from 2.8% to 34.9%. Six studies described wound healing time, varying from two to seven weeks. Four studies took repeated microbial swabs during subsequent vacuum dressing changes. One study reported newly detected pathogens in 23% of the included patients, and three studies did not find new pathogens. CONCLUSION This review provides an assessment of current literature on the role of NPWT in the management of soft tissue defects in patients with FRI. Due to the lack of uniformity in included studies, conclusions should be drawn with caution. Currently, there is no clear scientific evidence to support the use of NPWT as definitive treatment in FRI. At this stage, we can only recommend early soft tissue coverage (within days) with a local or free flap. NPWT may be safe for a few days as temporarily soft tissue coverage until definitive soft tissue management could be performed. However, comparative studies between NPWT and early wound closure in FRI patients are needed.
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Affiliation(s)
- Susan Haidari
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank F. A. IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, Netherlands
| | | | - Wies Maarse
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - H. Charles Vogely
- Department of Orthopedic Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Alex J. Ramsden
- Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Bone Infection Unit, Nuffield Orthopedic Centre, Oxford, UK
| | | | - Geertje A. M. Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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33
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What is the diagnostic value of the Centers for Disease Control and Prevention criteria for surgical site infection in fracture-related infection? Injury 2021; 52:2879-2885. [PMID: 34412852 DOI: 10.1016/j.injury.2021.08.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/31/2021] [Accepted: 08/04/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fracture-related infection (FRI) remains one of the most challenging complications in orthopaedic trauma surgery. An early diagnosis is of paramount importance to guide treatment. The primary aim of this study was to compare the Centers for Disease Control and Prevention (CDC) criteria for the diagnosis of organ/space surgical site infection (SSI) to the recently developed diagnostic criteria of the FRI consensus definition in operatively treated fracture patients. METHODS This international multicenter retrospective cohort study evaluated 257 patients with 261 infections after operative fracture treatment. All patients included in this study were considered to have an FRI and treated accordingly ('intention to treat'). The minimum follow-up was one year. Infections were scored according to the CDC criteria for organ/space SSI and the diagnostic criteria of the FRI consensus definition. RESULTS Overall, 130 (49.8%) FRIs were captured when applying the CDC criteria for organ/space SSI, whereas 258 (98.9%) FRIs were captured when applying the FRI consensus criteria. Patients could not be classified as having an infection according to the CDC criteria mainly due to a lack of symptoms within 90 days after the surgical procedure (n = 96; 36.8%) and due to the fact that the surgery was performed at an anatomical localization not listed in the National Healthcare Safety Network (NHSN) operative procedure code mapping (n = 37; 14.2%). CONCLUSION This study confirms the importance of standardization with respect to the diagnosis of FRI. The results endorse the recently developed FRI consensus definition. When applying these diagnostic criteria, 98.9% of the infections that occured after operative fracture treatment could be captured. The CDC criteria for organ/space SSI captured less than half of the patients with an FRI requiring treatment, and seemed to have less diagnostic value in this patient population.
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34
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Kuipers JH, Bos PK, Meuffels DE. Facial subcutaneous emphysema due to rectum injury after pelvic fracture. BMJ Case Rep 2021; 14:14/7/e241542. [PMID: 34210699 DOI: 10.1136/bcr-2020-241542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 35-year old dockworker sustained a pelvic injury when he was caught by a large loading clamshell grab. Primary survey revealed an open book pelvic fracture with soft tissue defects of the left thigh and groin. CT scanning of the thorax and abdomen did not reveal significant additional injuries. Partly due to patient's haemodynamical instability, osteosynthesis of the pelvic fracture was performed immediately after resuscitation, whereby the severely contaminated wound of the thigh was debrided and irrigated. The following days, progressive facial subcutaneous emphysema developed, but patient remained clinically stable. Several specialists were consulted, but did not find a cause. At day 7, a second surgery was planned to treat a pelvic surgical wound infection. Unexpectedly, we found faecal contamination in the pelvic surgical wound. The consulted gastro/intestinal-surgeon performed a laparoscopic colostomy for a rectal laceration. Awareness for bowel injuries with open pelvic fracture should be high, also when subcutaneous emphysema is found remotely.
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Affiliation(s)
- Joost H Kuipers
- Department of Orthopaedic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - P Koen Bos
- Department of Orthopaedic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Duncan E Meuffels
- Department of Orthopaedic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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Affiliation(s)
- Susanne Baertl
- AO Research Institute Davos, Davos, Switzerland.,Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | | | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | | | | | - Katie Young
- AO Research Institute Davos, Davos, Switzerland
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36
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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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37
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Brinker MR, Macek J, Laughlin M, Dunn WR. Utility of Common Biomarkers for Diagnosing Infection in Nonunion. J Orthop Trauma 2021; 35:121-127. [PMID: 33105452 DOI: 10.1097/bot.0000000000001925] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the diagnostic utility of leukocyte count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) for distinguishing between septic and aseptic nonunions. DESIGN A single-gate (cohort) design was used, using 1 set of eligibility criteria applied to a consecutive sample of nonunions. SETTING Private quaternary referral center. PATIENTS/PARTICIPANTS Inclusion criteria were consecutive patients (≥18 years) with a nonunion requiring surgery that allowed for direct or medullary canal tissue sampling from the nonunion site. The cohort included 204 subjects with 211 nonunions. INTERVENTION Blood samples were drawn for laboratory analysis of WBC, ESR, and CRP before surgery. MAIN OUTCOME MEASUREMENTS The reference standard used to define infection was the fracture-related infection confirmatory criteria. Measures of diagnostic accuracy were calculated. To assess the additional diagnostic gain of each index lab test while simultaneously considering the others, logistic regression models were fit. RESULTS The prevalence of infection was 19% (40 of 211 nonunion sites). The positive likelihood ratios (95% confidence interval) for WBC, ESR, and CRP were 1.07 (0.38-3.02), 1.27 (0.88-1.82) and 1.57 (0.94-2.60), respectively. Multivariable modeling adjusted for the effect of preoperative antibiotics showed that WBC (P = 0.42), ESR (P = 0.48), and CRP (P = 0.23) were not significant predictors of infection. CONCLUSIONS In this consecutive sample of 211 nonunions in whom standard clinical practice would be to obtain index lab tests, our findings showed that WBC, ESR, and CRP were not significant predictors of infection. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mark R Brinker
- Fondren Orthopedic Research Institute, Houston, TX
- Fondren Orthopedic Group, Houston, TX; and
- Texas Orthopedic Hospital, Houston, TX
| | - Jenny Macek
- Fondren Orthopedic Group, Houston, TX; and
- Texas Orthopedic Hospital, Houston, TX
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38
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Impact of duration of perioperative antibiotic prophylaxis on development of fracture-related infection in open fractures. Arch Orthop Trauma Surg 2021; 141:235-243. [PMID: 32409906 DOI: 10.1007/s00402-020-03474-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Infection is a common complication of open fractures potentially leading to nonunion, functional loss, and even amputation. Perioperative antibiotic prophylaxis (PAP) is standard practice for infection prevention in the management of open fractures. However, optimal duration of PAP remains controversial. The objectives were to assess whether PAP duration is independently associated with infection in open fractures and if administration of PAP beyond the commonly-recommended limit of 72 h has any effect on the infection rate. MATERIALS AND METHODS Over a 14-year period from 2003 to 2017, 530 skeletally-mature patients with operatively-treated, non-pathologic, long-bone open fractures were treated at one institution. Twenty-eight patients were excluded because of death or loss to follow-up and the remaining 502 patients (with 559 open fractures) who completed a 24-month follow-up were included in this retrospective study. The outcome was fracture-related infection (FRI), defined by the criteria of a recent consensus definition. A logistic generalized estimating equations regression model was conducted, including PAP duration and variables selected by a least absolute shrinkage and selection operator (LASSO) method, to assess the association between PAP duration and FRI. Propensity score analysis using a 72-h cut-off was performed to further cope with confounding. RESULTS PAP duration, adjusted for the LASSO selected predictors, was independently associated with FRI (OR: 1.11 [95%CI, 1.04-1.19] for every one-day increase in PAP duration, p = 0.003). PAP duration longer than 72 h did not significantly increase the odds for FRI compared to shorter durations (p = 0.06, analysis adjusted for propensity score). CONCLUSIONS This study found no evidence that administration of prophylactic antibiotics beyond 72 h in patients with long-bone open fractures is warranted. Analyses adjusted for known confounders even revealed a higher risk for FRI for longer PAP. However, this effect cannot necessarily be considered as causal and further research is needed.
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39
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McNally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC, Clauss M, Higuera CA, Trebše R. The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B:18-25. [PMID: 33380199 PMCID: PMC7954183 DOI: 10.1302/0301-620x.103b1.bjj-2020-1381.r1] [Citation(s) in RCA: 269] [Impact Index Per Article: 89.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition. Methods This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance. Results This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI. Conclusion The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: Bone Joint J 2021;103-B(1):18–25.
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Affiliation(s)
- Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Ricardo Sousa
- Porto Bone Infection Group (GRIP), Orthopaedic Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Antonia F Chen
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - H Charles Vogely
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martin Clauss
- Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic, Florida, USA
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40
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Metsemakers WJ, Zalavras C, Schwarz EM, Chen AF, Trampuz A, Moriarty TF. Antimicrobial Resistance, the COVID-19 Pandemic, and Lessons for the Orthopaedic Community. J Bone Joint Surg Am 2021; 103:4-9. [PMID: 33259429 DOI: 10.2106/jbjs.20.01214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Antimicrobial resistance (AMR) is widely regarded as one of the most important global public health challenges of the twenty-first century. The overuse and the improper use of antibiotics in human medicine, food production, and the environment as a whole have unfortunately contributed to this issue. Many major international scientific, political, and social organizations have warned that the increase in AMR could cost the lives of millions of people if it is not addressed on a global scale. Although AMR is already a challenge in clinical practice today, it has taken on a new importance in the face of the coronavirus disease 2019 (COVID-19) pandemic. While improved handwashing techniques, social distancing, and other interventional measures may positively influence AMR, the widespread use of antibiotics to treat or prevent bacterial coinfections, especially in unconfirmed cases of COVID-19, may have unintended negative implications with respect to AMR. Although the exact number of bacterial coinfections and the rate at which patients with COVID-19 receive antibiotic therapy remain to be accurately determined, the pandemic has revived the discussion on antibiotic overuse and AMR. This article describes why the COVID-19 pandemic has increased our awareness of AMR and presents the immense global impact of AMR on society as a whole. Furthermore, an attempt is made to stress the importance of tackling AMR in the future and the role of the orthopaedic community in this worldwide effort.
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Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Edward M Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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41
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Maleitzke T, Eckerlin P, Winkler T, Trampuz A. [Prevention of infections following open fractures]. DER ORTHOPADE 2020; 49:679-684. [PMID: 32671415 DOI: 10.1007/s00132-020-03952-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Open fractures involve a high risk of open fracture-associated infections (OFAIs), and the treatment can often be protracted and complicated. Thus, prevention of OFAIs in the acute and perioperative management of open fractures is of great importance. Through vigilance and thorough treatment planning, between the day of injury and the hospital discharge, the risk of OFAIs can be considerably reduced.
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Affiliation(s)
- Tazio Maleitzke
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland. .,Julius-Wolff-Institut, Charité - Universitätsmedizin Berlin, Berlin, Deutschland. .,Berlin Institute of Health, Berlin, Deutschland.
| | - Petra Eckerlin
- Klinik für Orthopädie und Unfallchirurgie, Klinikum in der Pfeifferschen Stiftungen, Magdeburg, Deutschland
| | - Tobias Winkler
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.,Julius-Wolff-Institut, Charité - Universitätsmedizin Berlin, Berlin, Deutschland.,Berlin Institute of Health, Berlin, Deutschland.,Berlin-Institute of Health, Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andrej Trampuz
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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42
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How to Diagnose Surgical Site Infection After Fracture Surgery: We Have a Problem! Tech Orthop 2020. [DOI: 10.1097/bto.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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