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Fracture-related infection

2021; Journal of Bone and Joint Surgery; Volume: 10; Issue: 6 Linguagem: Inglês

10.1302/2046-3758.106.bjr-2021-0167.r1

2046-3758

Susanne Baertl, Willem‐Jan Metsemakers, Mario Morgenstern, Volker Alt, R. Geoff Richards, T. Fintan Moriarty, Katie Young,

Osteomyelitis and Bone Disorders Research

Bone & Joint ResearchVol. 10, No. 6 InfographicOpen AccessOpen Access licenseFracture-related infectionCrossMarkSusanne Baertl, Willem-Jan Metsemakers, Mario Morgenstern, Volker Alt, Robert Geoff Richards, Thomas Fintan Moriarty, Katie YoungSusanne BaertlOrthopaedic Trauma SurgeonAO Research Institute Davos, Davos, SwitzerlandDepartment of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany, Willem-Jan MetsemakersOrthopaedic Trauma Surgeonhttps://orcid.org/0000-0002-4114-9093Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium, Mario MorgensternOrthopaedic Trauma SurgeonCenter for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland, Volker AltProfessor, Chairman, and Directorhttps://orcid.org/0000-0003-0208-4650Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany, Robert Geoff RichardsDirectorhttps://orcid.org/0000-0002-7778-2480AO Research Institute Davos, Davos, Switzerland, Thomas Fintan MoriartyPrincipal ScientistThomas Fintan Moriarty. E-mail: E-mail Address: [email protected]https://orcid.org/0000-0003-2307-0397AO Research Institute Davos, Davos, Switzerland, Katie YoungOrthopaedic Trauma SurgeonAO Research Institute Davos, Davos, SwitzerlandPublished Online:2 Jun 2021https://doi.org/10.1302/2046-3758.106.BJR-2021-0167.R1AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail Cite this article: Bone Joint Res 2021;10(6):351–353.BackgroundFracture-related infection (FRI) carries a substantial burden of disease and socio-economic costs.1-3 The incidence of FRI is 1% to 2% in closed fractures and can reach 30% in open fractures.1 Until recently, amputation and recurrence rates remained high.2,4 With the publication of international consensus documents,4,5 an evidence-based overview of diagnosis and management has been provided, which should improve treatment outcomes.PathologyThe pathology of FRI is multifactorial; bacterial infection and fracture instability are interdependent and fundamental in FRI.6,7 Biofilm formation, canalicular invasion,8 intracellular infection,9 and formation of staphylococcal abscess communities10 are the key niches occupied by bacteria. A vicious cycle between instability with ongoing soft-tissue trauma, compromised neovascularity, and osteolysis creates a supportive environment for bacteria, promoting the development of FRI or hindering its eradication.6DiagnosisConfirmatory criteria include fistula or sinus tract, purulent drainage or pus, microbial growth in two or more deep tissue samples, and histological evidence of pathogens and inflammation in peri-implant tissue.4,5 Suggestive criteria include clinical signs such as: erythema; swelling; persistent, increasing, or new-onset wound drainage; radiological or nuclear imaging signs; increased serum inflammatory markers; and microbial growth in a single deep tissue sample.5,7ManagementA consensus-derived management algorithm has been developed and should be led by a multidisciplinary team.5,7 Based on three basic principles, consisting of exchange, retention, or removal of the indwelling implant, the preferred strategy depends on host physiology, time interval between fracture fixation and FRI manifestation, anatomical localization, and causative pathogen. For implant retention, the stability of the construct and the ability to perform proper debridement are critical, considering the implant type and soft-tissue conditions.7PreventionAppropriate use of prophylactic antibiotics is crucial to prevent FRI. In closed injuries, perioperative antibiotic prophylaxis limited to a single dose is recommended. In open fractures, prophylactic antibiotic administration should not exceed 24 hours for Gustilo-Anderson types I and II and 72 hours for Gustilo-Anderson type III fractures.5,7 Early debridement, soft-tissue management, and stable fracture fixation are cornerstones of management.5Follow-up of FRI should be planned in collaboration with a multidisciplinary team, for a minimum of 12 months after the cessation of surgical and antibiotic therapy.11Future perspectives for prevention and management of FRI include: antimicrobial coated implants; osteoinductive antibiotic-loaded biomaterials; and bacteriophage and enzybiotic therapy. All these therapies consider the global threat of antibiotic resistance and target mechanisms of antimicrobial tolerance such as biofilm formation.1References1. Metsemakers WJ, Kuehl R, Moriarty TF, et al. Infection after fracture fixation: Current surgical and microbiological concepts. Injury. 2018;49(3):511–522. Crossref, Medline, ISI, Google Scholar2. Metsemakers W-. J, Smeets B, Nijs S, Hoekstra H. Infection after fracture fixation of the tibia: Analysis of healthcare utilization and related costs. Injury. 2017;48(6):1204–1210. Crossref, Medline, ISI, Google Scholar3. Bezstarosti H, Van Lieshout EMM, Voskamp LW, et al. Insights into treatment and outcome of fracture-related infection: A systematic literature review. Arch Orthop Trauma Surg. 2019;139(1):61–72. Crossref, Medline, ISI, Google Scholar4. Metsemakers WJ, Morgenstern M, McNally MA, et al. Fracture-related infection: A consensus on definition from an international expert group. Injury. 2018;49(3):505–510. Crossref, Medline, ISI, Google Scholar5. Obremskey WT, Metsemakers W-J, Schlatterer DR, et al. Musculoskeletal infection in orthopaedic trauma: Assessment of the 2018 international consensus meeting on musculoskeletal infection. J Bone Joint Surg Am. 2020;102-A(10):e44. Crossref, ISI, Google Scholar6. Foster AL, Moriarty TF, Zalavras C, Morgenstern M, Jaiprakash A, Crawford R. The influence of biomechanical stability on bone healing and fracture-related infection: the legacy of Stephan Perren. Injury. 2020;52(1):43–52. Crossref, Medline, ISI, Google Scholar7. Depypere M, Morgenstern M, Kuehl R, Senneville E, Moriarty TF, Obremskey WT. Pathogenesis and management of fracture-related infection. Clin Microbiol Infect. 2020;26(5):572–578. Crossref, Medline, ISI, Google Scholar8. de Mesy Bentley KL, Trombetta R, Nishitani K, et al. Evidence of staphylococcus aureus deformation, proliferation, and migration in canaliculi of live cortical bone in murine models of osteomyelitis. J Bone Miner Res. 2017;32(5):985–990. Crossref, Medline, ISI, Google Scholar9. Mohamed W, Sommer U, Sethi S, Domann E, Thormann U, Schütz I. Intracellular proliferation of S. aureus in osteoblasts and effects of rifampicin and gentamicin on S. aureus intracellular proliferation and survival. Eur Cell Mater. 2014;28:258–268. Crossref, Medline, ISI, Google Scholar10. Hofstee MI, Riool M, Terjajevs I, et al. Three-Dimensional In Vitro Staphylococcus aureus Abscess Communities Display Antibiotic Tolerance and Protection from Neutrophil Clearance. Infect Immun. 2020;88(11):e00293-20. Crossref, Medline, ISI, Google Scholar11. Metsemakers W-J, Morgenstern M, Senneville E, et al. General treatment principles for fracture-related infection: Recommendations from an international expert group. Arch Orthop Trauma Surg. 2020;140(8):1013–1027. Crossref, Medline, ISI, Google ScholarAuthor contributionsS. Baertl: Designed, created, and revised the infographic.W-J. Metsemakers: Designed and revised the infographic.M. Morgenstern: Designed and revised the infographic.V. Alt: Designed and revised the infographic.R. G. Richards: Revised the infographic.T. F. Moriarty: Conceptualized, designed, and revised the infographic.K. Young: Designed and revised the infographic.Funding statementNo benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.AcknowledgementsWe acknowledge the contribution of Medical Artist Louise Hinman in preparing the illustrations for this infographic.TwitterFollow T. F. Moriarty @fintan_moriarty© 2021 Author(s) et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/.FiguresReferencesRelatedDetailsCited ByApplication of 68Ga-citrate PET/CT for differentiating periprosthetic joint infection from aseptic loosening after joint replacement surgeryTingting Xu, Yalan Zeng, Xiao Yang, Guangfu Liu, Taiyong Lv, Hongbin Yang, Fei Jiang, Yue Chen22 June 2022 | Bone & Joint Research, Vol. 11, No. 6Fracture-related infection in osteoporotic bone causes more severe infection and further delays healingJie Li, Ronald Man Yeung Wong, Yik Lok Chung, Sharon Shui Yee Leung, Simon Kwoon-Ho Chow, Margaret Ip, Wing-Hoi Cheung1 February 2022 | Bone & Joint Research, Vol. 11, No. 2Tibial bone and soft-tissue concentrations following combination therapy with vancomycin and meropenem – evaluated by microdialysis in a porcine model should patients with open fractures have higher doses of antibiotics?Sofus Ørbæk Vittrup, Pelle Hanberg, Martin Bruun Knudsen, Sara Kousgaard Tøstesen, Josephine Olsen Kipp, Jakob Hansen, Nis Pedersen Jørgensen, Maiken Stilling, Mats Bue18 February 2022 | Bone & Joint Research, Vol. 11, No. 2Terminology of bone and joint infectionMarkus Rupp, Nike Walter, Susanne Baertl, Siegmund Lang, David W. Lowenberg, Volker Alt17 November 2021 | Bone & Joint Research, Vol. 10, No. 11 Vol. 10, No. 6 Metrics Downloaded 1,891 times History Published online 2 June 2021 Information© 2021 Author(s) et al.KeywordsInfectionFractureTraumaPDF download