Fracture-related infection: current methods for prevention and treatment

ABSTRACT

Introduction: Fracture-related infection (FRI) is a serious complication related to orthopedic trauma, both from an infectious disease and a surgical point of view. The lack of scientific data with respect to diagnostic criteria and treatment principles of this entity has hampered efforts for an evidence-based approach and, as such, practices to prevent and treat FRI are often extrapolated from peri-prosthetic joint infection (PJI) literature. Recently, consensus guidelines were developed with respect to prevention, diagnosis and treatment of FRI.

Areas covered: This review will define FRI and approaches to prevent and treat this complication will be discussed, with an emphasis on antimicrobial and surgical considerations. Guidelines focusing on FRI will be highlighted and aspects of pre-clinical research with imminent translational potential described.

Expert opinion: New strategies are currently under investigation to improve the outcome of this sometimes-devastating complication. Local delivery of antimicrobials seems to be a promising approach; however, further high-quality clinical research is necessary to demonstrate efficacy. Delivery mechanisms for local antimicrobials include polymethyl methacrylate, implant coatings, collagen fleece, hydrogels and ceramics. The reintroduction of antimicrobials such as bacteriophage therapy has demonstrated promise in the management of drug-resistant organisms.

KEYWORDS:

• Fracture-related infection
• biofilm
• orthopedic
• prevention
• treatment
• locally delivered antimicrobial
• bacteriophage
• fracture
• infection

Article highlights

• An expert consensus guideline has recently been established defining Fracture-Related Infection (FRI)

• Preventing FRI requires a multidisciplinary approach incorporating systemic prophylactic antibiotic therapy, fracture stabilization and soft tissue coverage. Local antibiotic therapy may also have added value.

• Treatment of FRI depends on multiple factors including duration of infection and stability of the fracture fixation. An approach with debridement, antibiotic therapy and implant retention requires a stable construct. This is most likely to succeed with minimal time from infection onset and therefore minimal time for biofilm maturation.

• Polymethyl methacrylate bone cement has historically been the cornerstone of delivering local antibiotics in orthopedic and trauma surgery, yet it has many disadvantages including a suboptimal release profile and requirement for removal. Bioresorbable delivery mechanisms are being developed to broaden the indications in which local antibiotics can be used and to enhance pharmacokinetic release.

• Bacteriophage therapy is emerging as a promising treatment of multi-drug resistant organisms and is being applied as a salvage procedure in FRI.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was funded by the AO Foundation.