Conclusion and recommendations
FRI remains a challenging complication. To improve overall outcome, we should aim for standardized recommendations for diagnosis and treatment. This review focuses on delivering these recommendations (Table
3), in combination with an optimal treatment pathway for FRI patients (Fig.
1) based on up-to-date scientific evidence and expert opinion.
Table 3
Key recommendations
A well-established diagnosis is the first step in the treatment process of FRI patients. The presence of confirmatory signs should prompt treatment for FRI. Suggestive signs should motivate the medical team to further investigate the probability of an FRI A multidisciplinary approach is a key aspect in FRI treatment and should be implemented. The exact composition of the MDT will depend on the patient’s needs and local preferences It is recommended to refer complex cases to specialized centers where an MDT is available and physicians are experienced with the treatment of FRI The patient’s health status should be optimized. Optimization strategies should be started in consultation with the MDT and preferably preoperatively, if the clinical status allows it Patients who are nutritionally at risk for malnutrition should be considered for screening and, depending on the severity, a multidisciplinary approach (e.g. endocrinologists, nutritionists, geriatrics) for the optimization of this status should be implemented Fracture stability is of key importance with respect to the surgical treatment of FRI Thorough debridement is essential as well as adequate management of the dead space that may be created Low-pressure irrigation should be performed with a sufficient amount of normal saline in order to thoroughly clean the surgical field and to lower the bacterial load The application of local antimicrobials should be strongly considered NPWT should only be used as a short bridge to definite soft tissue coverage In case of FRI, start empiric broad-spectrum antibiotic therapy after tissue sampling A minimum follow-up of 12 months after cessation of (surgical and antibiotic) therapy is recommended, with the follow-up frequency depending on local policies and preferences Standardized patient outcome measures for FRI are currently not available. PROMIS seems to be the preferred tool to assess the patients’ short and long-term outcome |
Starting from the first patient contact, a full diagnostic work-up should be performed, considering the recently published diagnostic criteria [
3,
4]. The presence of suggestive signs should encourage the MDT to further investigate the probability of an FRI and to look for confirmative signs. The presence of confirmative signs should prompt treatment, based on host type and a multidisciplinary approach. If the patient is otherwise healthy the treatment plan can be started immediately. In the case of compromised hosts—based on the ASA score and assessment of the local health status—patient optimization should be initiated as soon as feasible, depending on the clinical status (e.g. sepsis, severe bony instability) of the patient.
Surgical treatment entails multiple key aspects (e.g. sampling, debridement, local antimicrobial therapy, soft tissue management, bone defect reconstruction). A judicious well-planned debridement remains one of the cornerstones in the treatment of FRI. The surgeon should give special attention to obtaining uncontaminated deep tissue samples for microbiology and histopathology. Immediately after tissue sampling, empiric broad-spectrum antibiotics should be started in case an FRI is suspected. Based on the result of tissue cultures and the corresponding antibiogram(s), antibiotic therapy needs to be adapted. OPAT can be considered in cases where longstanding IV antibiotic therapy is necessary. Regular follow-up is needed to monitor therapy, identify complications early and maximize functional outcome. Finally, follow-up of a minimum 12 months after cessation of (surgical and antibiotic) therapy is recommended.
Clinical outcomes of fracture union and absence of infection recurrence are important, but standardized patient-reported outcome measures are also critical.
Acknowledgements
This manuscript was developed by the FRI consensus group (supported by the AO Foundation, Orthopaedic Trauma Association (OTA), Pro-Implant Foundation and the European Bone and Joint Infection Society (EBJIS)). We specifically would like to thank the Anti-Infection Task Force (AOTK System; Claas Albers) and the Clinical Priority Program Bone Infection (AOTrauma; Philipp Buescher) for their support of the consensus meetings that were convened in 2016 (Davos, Switzerland) and 2018 (Zürich, Switzerland). Furthermore, we would like to thank Lois Wallach (AOTK System) for her assistance in preparing and proofreading this manuscript. Members of the FRI consensus group: Willem-Jan Metsemakers, MD, PhD (Chair); Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium. William T. Obremskey, MD, MPH (Chair); Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, United States of America. Martin A. McNally, MD, FRCS(Orth) (Chair); The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom. Nick Athanasou, MD, PhD, MRCP, FRCPath; The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom. Bridget L. Atkins, MD, MBBS, MSc, FRCP, FRCPath; The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom. Olivier Borens, MD, PhD; Orthopedic Department of Septic Surgery, Orthopaedic-Trauma Unit, Department for the Musculoskeletal System, CHUV, Lausanne, Switzerland. Melissa Depypere, MD; Department of Laboratory Medicine, University Hospitals Leuven, Belgium. Henrik Eckardt, MD; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland. Kenneth A. Egol, MD; Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA. William Foster, MD; Department of Orthopaedic Surgery, Virginia Commonwealth University, USA. Austin T. Fragomen, MD; Hospital for Special Surgery, Limb Lengthening & Complex Reconstruction Service, New York, NY, USA. Geertje A.M. Govaert, MD, PhD; Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands. Sven Hungerer, MD; Department of Joint Surgery and Arthroplasty, Trauma Center Murnau, Murnau Germany and Paracelsus Medical University (PMU) Salzburg, Austria. Stephen L. Kates, MD; Department of Orthopaedic Surgery, Virginia Commonwealth University, USA. Richard Kuehl, MD; Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Switzerland. Leonard Marais, MD, PhD; Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa. Ian Mcfadyen, MD; Department of Orthopaedic Surgery, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom. Mario Morgenstern, MD; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland. T. Fintan Moriarty, PhD; AO Research Institute Davos, Switzerland. Peter Ochsner, MD; Medical University Basel, Switzerland. Alex Ramsden, MD; The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom. Michael Raschke, MD, PhD; Department of Trauma Surgery, University Hospital of Münster, Germany. R. Geoff Richards, PhD; AO Research Institute Davos, Switzerland. Carlos Sancineto, MD; Department of Orthopaedics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. Charalampos Zalavras, MD, PhD; Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA. Eric Senneville, MD, PhD; Department of Infectious Diseases, Gustave Dron Hospital, University of Lille, France. Andrej Trampuz, MD; Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany. Michael H.J. Verhofstad, MD, PhD; Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands. Werner Zimmerli, MD; Interdisciplinary Unit for Orthopedic Infections, Kantonsspital Baselland, Rheinstrasse 26, 4410, Liestal, Switzerland.
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