Management of fracture-related infection in low resource settings: how applicable are the current consensus guidelines?

Abstract

The global burden of fracture-related infection (FRI) is likely to be found in countries with limited healthcare resources and strategies are needed to ensure the best available practice is context appropriate. This study has two main aims: (i) to assess the applicability of recently published expert guidance from the FRI consensus groups on the diagnosis and management of FRI to low- and middle-income countries (LMICs); (ii) to summarise the available evidence on FRI, with consideration for strategies applicable to low resource settings. Data related to the International Consensus Meeting Orthopaedic Trauma Work Group and the International Fracture Related Infection Consensus Group FRI guidelines were collected including panel membership, country of origin, language of publication, open access status and impact factor of the journal of publication. The recommendations and guidelines were then summarised with specific consideration for relevance and applicability to LMICs. Barriers to implementation were explored within a group of LMIC residents and experienced workers. The authorship, evidence base and reach of the FRI consensus guidelines lack representation from low resource settings. The majority of authors (78.5–100%) are based in high-income countries and there are no low-income country collaborators listed in any of the papers. All papers are in English. The FRI consensus guidelines give a clear set of principles for the optimum management of FRI. Many of these – including the approach to diagnosis, multidisciplinary team working and some elements of surgical management – are achievable in low resource settings. Current evidence suggests that it is important that a core set of principles is prioritised but robust evidence for this is lacking. There are major organisational and infrastructure obstacles in LMICs that will make any standardisation of FRI diagnosis or management challenging. The detail of how FRI consensus principles should be applied in low resource settings requires further work. The important work presented in the current FRI consensus guidelines is relevant to low resource settings. However, leadership, collaboration, creativity and innovation will be needed to implement these strategies for communities who need it the most.

Aetiology of long bone chronic osteomyelitis: an analysis of the current situation in one region in Egypt

“…Several studies analysed the bacteriological profile in long bone osteomyelitis [3,[5][6][7][8][12][13][14][15][16]. Reports from low resources settings and developing countries are sparse [4,9,10,17,18]. Nevertheless, other studies investigated the aetiology and bacteriology of COM in a diabetic foot or joint replacement infection or mixed group of patients [19][20][21].…”

“…In this study, we aimed to raise voices about the differences in causes and bacteriological profiles of COM in low resources settings. The management of chronic osteomyelitis in low resources countries had more obstacles compared to the developed world [10]. However, the high-quality literature about the bacteriological spectrum and sensitivities profile was driven by developed countries [12,15].…”

“…This study aimed to analyse and discuss the microbiological results of intraoperatively collected samples of patients diagnosed with chronic osteomyelitis in one centre. With very few available published data from low resources regions [10], we planned to investigate the current situation to figure out the best way to control this debilitating disease and update our infection control measures.…”

Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group

“…McNally et al reported 96% eradication of infection in 76 infected tibial non-union cases treated by Ilizarov treatment protocols and either primary skin closure or flap cover during the index surgical procedure [ 30 ]. Others have similarly reported success rates of over 90% in patients suffering from chronic osteomyelitis managed with debridement and primary soft tissue closure at the same time [ 31 , 32 ].…”

Use of a Novel Anti-Infective Noble Metal Alloy-Coated Titanium Orthopedic Nail in Patients with Open Fractures: A Case Series from Malaysia

“…However, a major complication in surgery is postoperative fracture-related infection, which may lead to nail failure, revision surgeries, nail removal and, in severe cases, amputation or death [ 3 ]. There is limited information available on fracture-related infections in resource-limited settings, and a 2022 review noted that 78.5−100% of authors on fracture-related infection consensus guidelines were from high-income countries [ 4 ]. Nevertheless, a large, international prospective study using an international online database called the “Surgical Implant Generation Network” (SIGN) found that 11.9% of patients with IM nail-treated open tibial fractures treated in low- and middle-income countries developed fracture-related infections [ 5 ].…”