Duration of Perioperative Antibiotic Prophylaxis in Open Fractures:A Systematic Review and Critical Appraisal

Fracture-related infection (FRI) remains a serious complication in open fracture care. Adequate surgical treatment and perioperative antibiotic prophylaxis (PAP) are key factors influencing the outcome. However, data concerning the optimal duration of PAP is scarce. The aim of this systematic review was to provide an overview of current evidence on the association between PAP duration and FRI in open fractures. A comprehensive search on 13 January 2022, in Embase, Medline, Cochrane, Web of Science and Google Scholar revealed six articles. Most studies compared either 1 day versus 5 days of PAP or included a cut-off at 72 h. Although prolonged PAP was not beneficial in the majority of patients, the variety of antibiotic regimens, short follow-up periods and unclear description of outcome parameters were important limitations that were encountered in most studies. This systematic review demonstrates a lack of well-constructed studies investigating the effect of PAP duration on FRI. Based on the available studies, prolonged PAP does not appear to be beneficial in the prevention of FRI in open fractures. However, these results should be interpreted with caution since all included studies had limitations. Future randomized trials are necessary to answer this research question definitively

Validation of the diagnostic criteria of the consensus definition of fracture-related infection

Background: The recently developed fracture-related infection (FRI) consensus definition, which is based on specific diagnostic criteria, has not been fully validated in clinical studies. We aimed to determine the diagnostic performance of the criteria of the FRI consensus definition and evaluated the effect of the combination of certain suggestive and confirmatory criteria on the diagnostic performance. Methods: A multicenter, multi-national, retrospective cohort study was performed. Patients were subdivided into an FRI or a control group, according to the treatment they received and the recommendations from a multidisciplinary team (‘intention to treat’). Exclusion criteria were patients with an FRI diagnosed outside the study period, patients younger than 18 years of age, patients with pathological fractures or patients with fractures of the skull, cervical, thoracic and lumbar spine. Minimum follow up for all patients was 18 months. Results: Overall, 637 patients underwent revision surgery for suspicion of FRI. Of these, 480 patients were diagnosed with FRI, treated accordingly, and included in the FRI group. The other 157 patients were included in the control group. The presence of at least one confirmatory sign was associated with a sensitivity of 97.5%, a specificity of 100% and a high discriminatory value (AUROC 0.99, p < 0.001). The presence of a clinical confirmatory criterion or, if not present, at least one positive culture was associated with the highest diagnostic performance (sensitivity: 98.6%, specificity: 100%, AUROC: 0.99 (p < 0.001)). In the subgroup of patients without clinical confirmatory signs at presentation, specificities of at least 95% were found for the clinical suggestive signs of fever, wound drainage, local warmth and redness. Conclusions: The presence of at least one confirmatory criterion identifies the vast majority of patients with an FRI and was associated with an excellent diagnostic discriminatory value. Therefore, our study validates the confirmatory criteria of the FRI consensus definition. Infection is highly likely in case of the presence of a single positive culture with a virulent pathogen. When certain clinical suggestive signs (e.g., wound drainage) are observed (individually or in combination and even without a confirmatory criterion), it is more likely than not, that an infection is present

Diagnosis of fracture-related infection in patients without clinical confirmatory criteria:an international retrospective cohort study

Background: fracture-related infection (FRI) remains a serious complication in orthopedic trauma. To standardize daily clinical practice, a consensus definition was established, based on confirmatory and suggestive criteria. In the presence of clinical confirmatory criteria, the diagnosis of an FRI is evident, and treatment can be started. However, if these criteria are absent, the decision to surgically collect deep tissue cultures can only be based on suggestive criteria. The primary study aim was to characterize the subpopulation of FRI patients presenting without clinical confirmatory criteria (fistula, sinus, wound breakdown, purulent wound drainage or presence of pus during surgery). The secondary aims were to describe the prevalence of the diagnostic criteria for FRI and present the microbiological characteristics, both for the entire FRI population. Methods: a multicenter, retrospective cohort study was performed, reporting the demographic, clinical and microbiological characteristics of 609 patients (with 613 fractures) who were treated for FRI based on the recommendations of a multidisciplinary team. Patients were divided in three groups, including the total population and two subgroups of patients presenting with or without clinical confirmatory criteria. Results: clinical and microbiological confirmatory criteria were present in 77g and 87g of the included fractures, respectively. Of patients, 23g presented without clinical confirmatory criteria, and they mostly displayed one (31g) or two (23g) suggestive clinical criteria (redness, swelling, warmth, pain, fever, new-onset joint effusion, persisting/increasing/new-onset wound drainage). The prevalence of any suggestive clinical, radiological or laboratory criteria in this subgroup was 85g, 55g and 97g, respectively. Most infections were monomicrobial (64g) and caused by Staphylococcus aureus. Conclusion: clinical confirmatory criteria were absent in 23g of the FRIs. In these cases, the decision to operatively collect deep tissue cultures was based on clinical, radiological and laboratory suggestive criteria. The combined use of these criteria should guide physicians in the management pathway of FRI. Further research is needed to provide guidelines on the decision to proceed with surgery when only these suggestive criteria are present.</p

What is the diagnostic value of the Centers for Disease Control and Prevention criteria for surgical site infection in fracture-related infection?

Background: Fracture-related infection (FRI) remains one of the most challenging complications in orthopaedic trauma surgery. An early diagnosis is of paramount importance to guide treatment. The primary aim of this study was to compare the Centers for Disease Control and Prevention (CDC) criteria for the diagnosis of organ/space surgical site infection (SSI) to the recently developed diagnostic criteria of the FRI consensus definition in operatively treated fracture patients.   Methods: This international multicenter retrospective cohort study evaluated 257 patients with 261 infections after operative fracture treatment. All patients included in this study were considered to have an FRI and treated accordingly (‘intention to treat’). The minimum follow-up was one year. Infections were scored according to the CDC criteria for organ/space SSI and the diagnostic criteria of the FRI consensus definition.   Results: Overall, 130 (49.8%) FRIs were captured when applying the CDC criteria for organ/space SSI, whereas 258 (98.9%) FRIs were captured when applying the FRI consensus criteria. Patients could not be classified as having an infection according to the CDC criteria mainly due to a lack of symptoms within 90 days after the surgical procedure (n = 96; 36.8%) and due to the fact that the surgery was performed at an anatomical localization not listed in the National Healthcare Safety Network (NHSN) operative procedure code mapping (n = 37; 14.2%).    Conclusion: This study confirms the importance of standardization with respect to the diagnosis of FRI. The results endorse the recently developed FRI consensus definition. When applying these diagnostic criteria, 98.9% of the infections that occured after operative fracture treatment could be captured. The CDC criteria for organ/space SSI captured less than half of the patients with an FRI requiring treatment, and seemed to have less diagnostic value in this patient population

Corrigendum to:Validation of the diagnostic criteria of the consensus definition of fracture-related infection Injury (2022);53, pages 1867-1879 (Injury (2022) 53(6) (1867–1879), (S0020138322002091), (10.1016/j.injury.2022.03.024))

The authors regret that Michael H. J. Verhofstad was incorrectly affiliated to the University Medical Center Utrecht in The Netherlands. He is affiliated to the Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands. The authors would like to apologise for any inconvenience caused.</p

Evidence-Based Recommendations for Local Antimicrobial Strategies and Dead Space Management in Fracture-Related Infection

Summary:Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. However, debridement is often associated with the formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention not only for local antimicrobial activity but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI.Level of Evidence:Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence

Operative Environment

Postoperative SSIs are believed to occur via bacterial inoculation at the time of surgery or as a result of bacterial contamination of the wound via open pathways to the deep tissue layers.1–3 The probability of SSI is reflected by interaction of parameters that can be categorized into three major groups.2 The first group consists of factors related to the ability of bacteria to cause infection and include initial inoculation load and genetically determined virulence factors that are required for adherence, reproduction, toxin production, and bypassing host defense mechanisms. The second group involves those factors related to the defense capacity of the host including local and systemic defense mechanisms. The last group contains environmental determinants of exposure such as size, time, and location of the surgical wound that can provide an opportunity for the bacteria to enter the surgical wound, overcome the local defense system, sustain their presence, and replicate and initiate local as well as systemic inflammatory reactions of the host. The use of iodine impregnated skin incise drapes shows decreased skin bacterial counts but no correlation has been established with SSI. However, no recommendations regarding the use of skin barriers can be made (see this Workgroup, Question 27)

Interobserver reliability of classification and characterization of proximal humeral fractures: a comparison of two and three-dimensional CT

Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Members of the Science of Variation Group--fully trained practicing orthopaedic and trauma surgeons from around the world--were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (&kappa;) measure. Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from &quot;slight&quot; to &quot;fair.&quot; A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (&kappa; = 0.35 compared with 0.30, p &lt; 0.001) and on the AO classification (&kappa; = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that was observed for selection of the treatment for proximal humeral fractures. The lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports

No Job Name

Abstract Ankle syndesmotic injury does not necessarily lead to ankle instability; however, the coexistence of deltoid ligament injury critically destabilizes the ankle joint. Syndesmotic injury may occur in isolation or may be associated with ankle fracture. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test. Radiographic findings usually include increased tibiofibular clear space decreased tibiofibular overlap, and increased medial clear space. However, syndesmotic injury may not be apparent radiographically; thus, routine stress testing is necessary for detecting syndesmotic instability. The goals of management are to restore and maintain the normal tibiofibular relationship to allow for healing of the ligamentous structures of the syndesmosis. Fixation of the syndesmosis is indicated when evidence of a diastasis is present. This may be detected preoperatively, in the absence of fracture, or intraoperatively, after rigid fixation of the medial malleolus and fibula fractures. Failure to diagnose and stabilize syndesmotic disruption adversely affects outcome

Management of large sileletal defects with vascularized oddeous flaps

Large skeletal defects constitute a clinical problem, which considerably affects the functional ability of the patient and endangers the viability of the affected limb. The progress of microsurgery has offered an alternative method of management, the transfer of vascularized osseous flaps. The purpose of this study is to present our experience with use of the free vascularized fibular graft in the management of large skeletal defects.Thirty-one large skeletal defects of a mean length of 12 cm (5-26 cm) involving 31 patients (20 male and 11 female of a mean age of 25 years) were treated with the free vascularized fibular graft. The defects involved the tibia in 15 patients, the femur in 5, the forearm in 7, the humerus in 1 and the mandible or maxilla in 3 patients. The etiology of the defects comprised trauma in 17 patients (with septic nonunion in 13), congenital pseudarthrosis in 6, malignant neoplasms in 6, hematogenous osteomyelitis in 1 and radiation necrosis in 1 patient. Poor vascularity of the surrounding soft tissue envelope was present in the majority (61%) of cases. The graft configuration was straight in 23 patients, whereas in 8 it was modified by osteotomies. The fibula was transferred as an osseous flap in 21 and as a composite flap in 10 patients. Two vascularized fibular grafts were simultaneously transferred in 2 cases and the vascularized fibula was combined with allograft in 1 case. The mean follow-up time was 4 years (6 months to 10 years).Graft incorporation was complete in 87% of patients with union of 94% of the junction sites at a mean time of 3 months in the upper extremity, 4.5 months in the tibia, 5.3 months in the femur and 6 months in the mandible and maxilla. Osseous reconstruction was finally successful in 74% of cases, due to the development of nonunion following stress fractures. Satisfactory function was achieved in 75% of patients and specifically in 88% of upper extremity defects, 80% of tibia defects and 40% of femur defects. Soft tissue reconstruction was successful in 80% of composite flap transfers. There were 1.4 complications per patient in 48% of the patients, the most frequent being stress fractures (40% in tibia and 60% in femur reconstruction). Donor site morbidity was minor and transient.Large skeletal defects can be reconstructed with the free vascularized fibular graft with a satisfactory functional result in the majority of patients, even in the presence of poor vascularity of the surrounding soft tissue envelope or infection, which would compromise alternative methods. The successful application of the free vascularized fibula is based on the unique vascularity, morphology and composition of the graft. Reconstruction of the upper extremity can be achieved successfully in a short time. Management of large tibia defects can be accomplished in the majority of cases, however stress fractures are frequent and graft hypertrophy is necessary for resumption of full function. Reconstruction of the femur is often accompanied by complications and is not satisfactory. The application of the free vascularized fibular graft is technically demanding, requires experience in microsurgery and is accompanied by limitations and complications. This versatile graft, however, can provide a solution in the demanding clinical problem of large skeletal defects.Τα μεγάλα οστικά ελλείμματα αποτελούν κλινικό πρόβλημα, το οποίο όχι μόνο περιορίζει σημαντικά την λειτουργικότητα του ασθενούς, αλλά θέτει σε σοβαρό κίνδυνο την βιωσιμότητα του προσβεβλημένου άκρου. Η πρόοδος της μικροχειρουργικής έχει προσφέρει μια εναλλακτική μέθοδο αποκατάστασης, την μεταφορά αγγειούμενων οστικών μοσχευμάτων. Σκοπός της μελέτης αυτής είναι να παρουσιάσει την εμπειρία μας από την χρήση του ελεύθερου αγγειούμενου μοσχεύματος της περόνης στην αντιμετώπιση μεγάλων οστικών ελλειμμάτων.Αντιμετωπίσαμε 31 μεγάλα οστικά ελλείμματα, μέσου μεγέθους 12 εκατοστών (5 έως 26), σε ισάριθμους ασθενείς (20 άνδρες και 11 γυναίκες με μέση ηλικία τα 25 χρόνια). Η εντόπιση των ελλειμμάτων αφορούσε την κνήμη σε 15 ασθενείς, το μηριαίο σε 5, το αντιβράχιο σε 7, το βραχιόνιο σε 1 και την άνω ή κάτω γνάθο σε 3 ασθενείς. Η αιτιολογία των οστικών ελλειμμάτων ήταν τραύμα σε 17 ασθενείς (με παρουσία σηπτικής ψευδάρθρωσης στους 13), συγγενής ψευδάρθρωση σε 6 , κακοήθη νεοπλάσματα σε 6, αιματογενής οστεομυελίτιδα σε 1 και μετακτινική νέκρωση σε 1 ασθενή. Στις περισσότερες περιπτώσεις (61%) τα περιβάλλοντα μαλακά μόρια είχαν πτωχή αιμάτωση. Η διαμόρφωση των μοσχευμάτων ήταν ευθεία σε 23 ασθενείς, ενώ στους υπόλοιπους 8 τροποποιήθηκε με οστεοτομίες. Η περόνη μεταφέρθηκε ως αμιγώς οστικός κρημνός σε 21 ασθενείς, ενώ σε 10 ως σύνθετος κρημνός. Σε 2 ασθενείς χρησιμοποιήθηκαν ταυτόχρονα δύο αγγειούμενα μοσχεύματα, ενώ σε 1 ασθενή ο συνδυασμός αγγειούμενου μοσχεύματος περόνης και αλλομοσχεύματος. Το μέσο χρονικό διάστημα παρακολούθησης των ασθενών μας ήταν 4 χρόνια (6 μήνες έως 10 χρόνια).Η ενσωμάτωση του μοσχεύματος ήταν πλήρης στο 87% των ασθενών με πώρωση του 94% των περιοχών σύνδεσης σε χρονικό διάστημα 3 μηνών στο άνω άκρο, 4,5 μηνών στην κνήμη, 5,3 μηνών στο μηριαίο και 6 μηνών στην γνάθο. Η οστική αποκατάσταση ήταν επιτυχής τελικά στο 74% των περιπτώσεων λόγω ανάπτυξης ψευδάρθρωσης μετά από κατάγματα κοπώσεως. Η λειτουργική αποκατάσταση σε ελλείμματα των άκρων ήταν ικανοποιητική στο 75% των ασθενών και συγκεκριμένα στο 88% των ελλειμμάτων του άνω άκρου, στο 80% των ελλειμμάτων κνήμης και στο 40% των ελλειμμάτων μηριαίου. Η αποκατάσταση των μαλακών μορίων με σύνθετους κρημνούς ήταν επιτυχής στο 80% των περιπτώσεων. Συνολικά παρατηρήθηκαν 1,4 επιπλοκές ανά ασθενή στο 48% των ασθενών με συχνότερη την εμφάνιση καταγμάτων κόπωσης (40% στην κνήμη και 60% στο μηριαίο). Η νοσηρότητα της δότριας περιοχής ήταν μικρή και παροδική.Το ελεύθερο αγγειούμενο μόσχευμα της περόνης είναι δυνατόν να αποκαταστήσει μεγάλα οστικά ελλείμματα με ικανοποιητικό λειτουργικό αποτέλεσμα στην μεγάλη πλειονότητα των ασθενών, ακόμη και με παρουσία πτωχής αιμάτωσης των περιβαλλόντων μαλακών μορίων ή λοίμωξης, που θα καθιστούσαν προβληματική την χρησιμοποίηση εναλλακτικών μεθόδων αποκατάστασης. Η επιτυχής εφαρμογή της περόνης βασίζεται στα ιδιαίτερα χαρακτηριστικά της αγγείωσης, της μορφολογίας και της σύστασης του μοσχεύματος. Η αποκατάσταση των οστών του άνω άκρου με το αγγειούμενο μόσχευμα της περόνης είναι ιδιαίτερα αποτελεσματική και γρήγορη. Η αντιμετώπιση μεγάλων οστικών ελλειμμάτων κνήμης είναι επιτυχής στις περισσότερες περιπτώσεις, όμως τα κατάγματα κοπώσεως είναι συχνά και η υπερτροφία του μοσχεύματος είναι απαραίτητη για την επάνοδο του ασθενούς σε πλήρη δραστηριότητα. Η αποκατάσταση του μηριαίου συνοδεύεται συχνά από επιπλοκές και δεν είναι ικανοποιητική. Η εφαρμογή του ελέυθερου αγγειούμενού μοσχεύματος της περόνης είναι τεχνικά απαιτητική, προϋποθέτει εμπειρία στην μικροχειρουργική και δεν στερείται περιορισμών και επιπλοκών. Το πολυδύναμο αυτό μόσχευμα μπορεί να προσφέρει όμως λύση στο δυσεπίλυτο κλινικό πρόβλημα των μεγάλων οστικών ελλειμμάτων