Introduction
Methods
Literature search strategy
Data extraction
Analysis
Results
Location of FRI | All studies, N = 3711 |
---|---|
Tibia | 2533 (68.3%) |
Femur | 599 (16.1%) |
Ankle | 124 (3.3%) |
Calcaneus | 77 (2.1%) |
Foot | 63 (1.7%) |
Humerus | 59 (1.6%) |
Knee | 49 (1.3%) |
Fibula | 30 (0.8%) |
Radius | 24 (0.6%) |
Forearm | 24 (0.6%) |
Ulna | 18 (0.5%) |
Ilium | 13 (0.4%) |
Elbow | 11 (0.3%) |
Clavicle | 4 (0.1%) |
Spine | 1 (0.0%) |
Skull | 1 (0.0%) |
Not specified | 197 (5.3%) |
Lower extremity not defined | 41 (1.1%) |
Upper extremity not defined | 21 (0.6%) |
Diagnosis and classification
Parameters associated with FRI | Number of studies, N = 93 |
---|---|
Clinical signs | |
Purulent drainage (or discharge) | 34 (37%) |
Dolor (pain) | 14 (15%) |
Tumor (swelling) | 9 (10%) |
Calor (warmth) | 8 (9%) |
Rubor (redness) | 7 (8%) |
Wound dehiscence/breakdown | 7 (8%) |
Fever | 5 (5%) |
Unspecified | 46 (49%) |
Laboratory testing | |
C-reactive protein (CRP) | 17 (18%) |
Unspecified | 9 (10%) |
Radiological signs | |
Signs of osteomyelitis | 62 (67%) |
Evidence of non-union | 34 (37%) |
Bacteriological/histological findings | |
Cultures taken | 56 (60%) |
Unspecified histology | 17 (18%) |
Unspecified bacteriology | 15 (16%) |
Other | |
Time of infection | 27 (29%) |
No parameters for diagnosis given | 8 (9%) |
Classification System | Number of studies, N = 47 |
---|---|
Cierny-Mader classification | 34 (72%) |
May’s classification | 4 (9%) |
Jain and Sinha’s modified May classification | 2 (4%) |
Calori’s classification for non-union | 1 (2%) |
CDC guidelines for wound infection | 1 (2%) |
Osteomyelitis diagnosis score | 1 (2%) |
UTMB staging system for adult osteomyelitis | 1 (2%) |
Weiland classification | 1 (2%) |
Yang’s classification for bone defects | 1 (2%) |
Ziran’s algorithm for acute infection after ORIF | 1 (2%) |
Time frame | Number of studies N = 93 |
---|---|
Chronic infection | 12 (13%) |
> 6 weeks | 3 (3%) |
> 12 weeks | 3 (3%) |
> 4 months | 2 (2%) |
> 6 months | 4 (4%) |
Infected non-union | 12 (13%) |
> 3 months | 1 (1%) |
> 4 months | 1 (1%) |
> 6 months | 9 (10%) |
> 12 months | 1 (1%) |
Multiple divisions | 3 (3%) |
Acute < 2 weeks, Subacute 2–6 weeks, Chronic > 6 weeks | 1 (1%) |
Acute < 30 days, Subacute 1–6 months, Chronic > 6 months | 2 (2%) |
No period of time mentioned | 66 (71%) |
Surgical protocols
Number of stages | Number of studies, N = 93 |
---|---|
One-stage | 18 (19%) |
Two-stage | 50 (54%) |
Three-stage | 7 (8%) |
Combination of the above | 10 (11%) |
Unknown | 16 (17%) |
Type of fixation | Number of studies, N = 93 |
---|---|
Internal | 12 (13%) |
External | 27 (29%) |
Bone transport | 14 (15%) |
Mixed protocols | 34 (37%) |
Unknown | 14 (15%) |
Specialists involved | Number of studies, N = 12 |
---|---|
Trauma/orthopedic surgeon | 10 (83%) |
Infectious disease specialist | 5 (42%) |
Plastic surgeon | 5 (42%) |
Pharmacist | 1 (8%) |
Radiologist | 1 (8%) |
Team not defined | 3 (25%) |
Treatment specifications
Graft type used (62 studies) | N = 1418 (% of total) |
---|---|
Cancellous bone | 555 (39) |
Iliac crest | 445 (31) |
RIA (with BMP-7) | 76 (5) |
Tibia condyle | 25 (2) |
Femur condyle | 9 (1) |
Vascularized bone | 381 (27) |
Vascularized fibula | 322 (23) |
Latissimus dorsi with rib | 41 (3) |
Vascularized ilium | 18 (1) |
Other | 27 (2) |
Graft not defined | 455 (32) |
Total (41 studies) | N = 1171 (% of total) |
---|---|
Free flap | 460 (39) |
Latissimus dorsi | 206 (18) |
Not defined | 82 (7) |
Gracilis | 64 (5) |
Rectus abdominis | 47 (4) |
Scapular skin flap | 23 (2) |
Serratus anterior | 23 (2) |
Lateral thigh | 15 (1) |
Rotational flap | 125 (11) |
Gastrocnemius | 52 (4) |
Saphenous | 50 (4) |
Soleus | 23 (2) |
Skin | 247 (21) |
Split skin graft | 232 (20) |
Full thickness skin graft | 15 (1) |
Other | 76 (1) |
Skin/muscle not defined | 200 (17) |
Follow-up protocols
Parameter | Number of studies, N = 93 |
---|---|
Predefined routine follow-up episodes | 26 (28%) |
Clinical signs of infection | 31 (33%) |
Routine radiological check up | 49 (53%) |
Blood biomarkers | 32 (34%) |
C-reactive protein | 12 (13%) |
Erythrocyte sedimentation rate | 10 (11%) |
Leucocyte count | 4 (4%) |
Complete blood count | 2 (2%) |
Undefined | 4 (4%) |
Bone scoring systems | 5 (5%) |
ASAMI | 4 (4%) |
Bahr score | 1 (1%) |
Functional outcome scoring systems | 19 (20%) |
Self-defined functionality scores | 5 (5%) |
Paley’s functionality score | 3 (3%) |
American orthopaedic foot and ankle society score | 1 (1%) |
EuroQol 5D | 1 (1%) |
Johner-Wruhs evaluation criteria | 1 (1%) |
Lower extremity functionality scale | 1 (1%) |
Ma’s knee score | 1 (1%) |
Mazur’s ankle evaluation grading system | 1 (1%) |
Merchant and Dietz score | 1 (1%) |
SF-12 | 1 (1%) |
SF-36 | 1 (1%) |
Shahcheraghi and Bayatpoor evaluation score | 1 (1%) |
Stewart and Hundley criteria | 1 (1%) |
Surgical outcome
Proportional variable | Studies (N) | FRI (N) | Chi2 (p value) | I2 value (95% CI) | Pooled proportion (95% CI) |
---|---|---|---|---|---|
Primary healing | 93 | 3711 |
*
| 81% (77–84) | 85% (82–88) |
Total healing | 92 | 3695 |
*
| 77% (72–81) | 93% (91–94) |
Infection recurrence | 89 | 3598 |
*
| 73% (66–78) | 9% (7–11) |
Amputation rate | 83 | 3226 |
*
| 50% (35–61) | 3% (3–5) |
Continuous variable | Studies (N) | Patients (N) | Weighted meanb |
---|---|---|---|
Union time (months) | 47 | 1809 | 6.63 |
Surgical revisionsa | 58 | 2110 | 0.31 |
Complicationsa | 84 | 3436 | 0.38 |
HLOS (months) | 14 | 415 | 1.39 |