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

Abstract

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.

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

“…Given there are so many different views and no standardized criteria available, an equal comparison is not possible between studies. In the future this can and could be improved if researchers implement the recently developed consensus definition for FRI [108]. …”

“…The lack of a definition makes it difficult to compare studies. In March 2018 a consensus definition of FRI from an international expert group has been published [108], finally offering the possibility to standardize reports and improve published literature.…”

Chronic Osteomyelitis of the tibia and ankle treated with Limb Salvage Reconstruction

“…Patients with a suspected FRI included those with a history of previous FRI but with no sinus and only 1/5 isolated positive or no positive intraoperative cultures at index salvage surgery. [13] At latest follow-up, available patients completed a routine follow-up survey. The primary outcome was the ability to control infection without the need for amputation or chronic antibiotic suppression.…”

“…Chronic osteomyelitis is one of the most challenging problems encountered by orthopaedic surgeons. In the setting of fracture or prosthetic joint replacement, infection typically stems from local contamination [13] . Open tibia and ankle fractures occur with an incidence of 3.4 per 100,000 and 1.6 per 100,000 respectively [5,7] , and have a high propensity to develop fracture related infection (FRI) with associated chronic osteomyelitis.…”

Seasonal effect on the incidence of post-operative wound complications after trauma-related surgery of the foot, ankle and lower leg

“…This incidence is much higher compared to most other surgical procedures and is most likely related to the thin soft-tissue envelope and damage to vascularization during the injury [3]. Moreover, the fact that a fracture is involved, could have implications for the odds of developing surgical wound complications or, in recently defined terminology: "fracture related infection (FRI) [4]. Surgical wound complications, including FRIs and other SSIs can cause longer hospital stay or readmission, increased use of antibiotics and revision surgery, resulting in higher healthcare costs [5].…”