Definition of infection after fracture fixation: A systematic review of randomized controlled trials to evaluate current practice

Metsemakers, Willem‐Jan; Kortram, Kirsten; Morgenstern, Mario; Moriarty, T. Fintan; Meex, Ingrid; Kuehl, Richard; Nijs, Stefaan; Richards, R. Geoff; Raschke, Michael J.; Borens, Olivier; Kates, Stephen L.; Zalavras, Charalampos G.; Giannoudis, Peter V.; Verhofstad, M.H.J.

doi:10.1016/j.injury.2017.02.010

Cited by 79 publications

(54 citation statements)

References 99 publications

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“…Furthermore, only one study used a standardized definition for FRI (e.g., CDC guidelines) out of 47 studies using a definition. This is in line with conclusions of a previous review of 100 randomized clinical trials aimed at defining FRI [103]. …”

Section: Discussionsupporting

confidence: 92%

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Insights into treatment and outcome of fracture-related infection: a systematic literature review

Bezstarosti

Lieshout

Voskamp

et al. 2018

Arch Orthop Trauma Surg

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101

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IntroductionStandardized guidelines for treatment of fracture-related infection (FRI) are lacking. Worldwide many treatment protocols are used with variable success rates. Awareness on the need of standardized, evidence-based guidelines has increased in recent years. This systematic literature review gives an overview of available diagnostic criteria, classifications, treatment protocols, and related outcome measurements for surgically treated FRI patients.MethodsA comprehensive search was performed in all scientific literature since 1990. Studies in English that described surgical patient series for treatment of FRI were included. Data were collected on diagnostic criteria for FRI, classifications used, surgical treatments, follow-up protocols, and overall outcome. A systematic review was performed according to the PRISMA statement. Proportions and weighted means were calculated.ResultsThe search yielded 2051 studies. Ninety-three studies were suitable for inclusion, describing 3701 patients (3711 fractures) with complex FRI. The population consisted predominantly of male patients (77%), with the tibia being the most commonly affected bone (64%), and a mean of three previous operations per patient. Forty-three (46%) studies described FRI at one specific location. Only one study (1%) used a standardized definition for infection. A total of nine different classifications were used to guide treatment protocols, of which Cierny and Mader was used most often (36%). Eighteen (19%) studies used a one-stage, 50 (54%) a two-stage, and seven (8%) a three-stage surgical treatment protocol. Ten studies (11%) used mixed protocols. Antibiotic protocols varied widely between studies. A multidisciplinary approach was mentioned in only 12 (13%) studies.ConclusionsThis extensive literature review shows a lack of standardized guidelines with respect to diagnosis and treatment of FRI, which mimics the situation for prosthetic joint infection identified many years ago. Internationally accepted guidelines are urgently required to improve the quality of care for patients suffering from this significant complication.

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Section: Discussionsupporting

confidence: 92%

“…Due to heterogeneity it is almost impossible to compare outcome between studies. One explanation for this wide variety of published treatment strategies could be the lack of a consensus in the orthopedic trauma community regarding these strategies to manage FRI [103]. …”

Section: Discussionmentioning

confidence: 99%

Insights into treatment and outcome of fracture-related infection: a systematic literature review

Bezstarosti

Lieshout

Voskamp

et al. 2018

Arch Orthop Trauma Surg

Self Cite

101

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“…a 6 week transition from acute to chronic infection). All these concerns pose serious problems from a definition point of view [3]. Of course, the participants did agree that acute and chronic infections are different entities that may require different treatment strategies; however, it should not impact upon the way clinicians define FRI.…”

Section: Discussionmentioning

confidence: 99%

“…Interestingly, this issue was previously raised in an AO/ASIF scientific supplement publication by Arens et al in 1996, wherein the authors stated in a combined clinical and experimental study on FRI: 'It is astonishing that in all papers in which infection is mentioned, the term 'infection' is not defined' [2]. In fact, this was confirmed by a recent systematic review, which showed that only a minority of randomized controlled trials (2%) in fracture care use any kind of standardized definition of infection [3].…”

Section: Introductionmentioning

confidence: 99%

Fracture-related infection: A consensus on definition from an international expert group

Metsemakers

Morgenstern

McNally

et al. 2018

Injury

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524

509

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Fracture-related infection (FRI) is a common and serious complication in trauma surgery. Accurately estimating the impact of this complication has been hampered by the lack of a clear definition. The absence of a working definition of FRI renders existing studies difficult to evaluate or compare. In order to address this issue, an expert group comprised of a number of scientific and medical organizations has been convened, with the support of the AO Foundation, in order to develop a consensus definition. The process that led to this proposed definition started with a systematic literature review, which revealed that the majority of randomized controlled trials in fracture care do not use a standardized definition of FRI. In response to this conclusion, an international survey on the need for and key components of a definition of FRI was distributed amongst all registered AOTrauma users. Approximately 90% of the more than 2000 surgeons who responded suggested that a definition of FRI is required. As a final step, a consensus meeting was held with an expert panel. The outcome of this process led to a consensus definition of FRI. Two levels of certainty around diagnostic features were defined. Criteria could be confirmatory (infection definitely present) or suggestive. Four confirmatory criteria were defined: Fistula, sinus or wound breakdown; Purulent drainage from the wound or presence of pus during surgery; Phenotypically indistinguishable pathogens identified by culture from at least two separate deep tissue/implant specimens; Presence of microorganisms in deep tissue taken during an operative intervention, as confirmed by histopathological examination. Furthermore, a list of suggestive criteria was defined. These require further investigations in order to look for confirmatory criteria. In the current paper, an overview is provided of the proposed definition and a rationale for each component and decision. The intention of establishing this definition of FRI was to offer clinicians the opportunity to standardize clinical reports and improve the quality of published literature. It is important to note that the proposed definition was not designed to guide treatment of FRI and should be validated by prospective data collection in the future.

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“…We sometimes use the CDC guideline to prevent surgical-site infection (SSI), which distinguishes between superficial incisional, deep incisional and organ/space infections [13]. However, this guideline was not specifically developed for fracture patients [16], and for this reason, the term SSI is used in this review for lack of a clear alternate definition, although the authors are aware of the need for a consensus definition of FRI [18].…”

Section: Definitionmentioning

confidence: 99%

Prevention of fracture-related infection: a multidisciplinary care package

Metsemakers

Onsea

Neutjens

et al. 2017

International Orthopaedics (SICOT)

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Fracture-related infection (FRI) remains a challenging complication. It may result in permanent functional loss or even amputation in otherwise healthy patients. For these reasons, it is important to focus attention on prevention. In treatment algorithms for FRI, antibiotic stewardship programmes have already proved their use by means of a multidisciplinary collaboration between microbiologists, surgeons, pharmacists, infectious disease physicians and nursing staff. A similar approach, however, has not been described for infection prevention. As a first step towards achieving a multidisciplinary care package for infection prevention, this review summarises the most recent guidelines published by the World Health Organization (WHO) and US National Institutes of Health Centers for Disease Control and Prevention (CDC), primarily focusing on the musculoskeletal trauma patient. The implementation of these guidelines, together with close collaboration between infection control physicians, surgeons, anaesthesiologists and nursing staff, can potentially have a beneficial effect on the rate of FRI after musculoskeletal trauma surgery. It must be stated that most evidence presented here in support of these guidelines was not obtained from musculoskeletal trauma research. Although most preventive measures described in these studies can be generalised to the musculoskeletal trauma patient, there are still important differences with nontrauma patients that require further attention. Future research should therefore focus more on this very defined patient population and more specifically on FRI prevention.

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Definition of infection after fracture fixation: A systematic review of randomized controlled trials to evaluate current practice

Cited by 79 publications

References 99 publications

Insights into treatment and outcome of fracture-related infection: a systematic literature review

Insights into treatment and outcome of fracture-related infection: a systematic literature review

Fracture-related infection: A consensus on definition from an international expert group

Prevention of fracture-related infection: a multidisciplinary care package

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