Diagnosing Fracture-Related Infection: Current Concepts and Recommendations

Govaert, Geertje A. M.; Kuehl, Richard; Atkins, Bridget L; Trampuz, Andrej; Morgenstern, Mario; Obremskey, William T; Verhofstad, Michael H J; McNally, Martin A; Metsemakers, Willem-Jan

doi:10.1097/BOT.0000000000001614

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Diagnosing Fracture-Related Infection: Current Concepts and Recommendations

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Author(s): Geertje A. M. Govaert , MD, PhD ^* , Richard Kuehl , MD ^† , Bridget L. Atkins , MD ^‡ , Andrej Trampuz , MD ^§ , Mario Morgenstern , MD ^║ , William T. Obremskey , MD, MPH ^¶ , Michael H. J. Verhofstad , MD, PhD ^** , Martin A. McNally , MD, FRCS(Orth) ^‡ , Willem-Jan Metsemakers , MD, PhD ^†† ^,

Publication date (Electronic): 08 August 2019

Journal: Journal of Orthopaedic Trauma

Publisher: Journal of Orthopaedic Trauma

Keywords: fracture-related infection, diagnosis, diagnostic criteria, definition, clinical criteria, medical imaging, histopathology, microbiology, serum inflammatory markers, fracture, infection

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Abstract

Summary:

Fracture-related infection (FRI) is a severe complication after bone injury and can pose a serious diagnostic challenge. Overall, there is a limited amount of scientific evidence regarding diagnostic criteria for FRI. For this reason, the AO Foundation and the European Bone and Joint Infection Society proposed a consensus definition for FRI to standardize the diagnostic criteria and improve the quality of patient care and applicability of future studies regarding this condition. The aim of this article was to summarize the available evidence and provide recommendations for the diagnosis of FRI. For this purpose, the FRI consensus definition will be discussed together with a proposal for an update based on the available evidence relating to the diagnostic value of clinical parameters, serum inflammatory markers, imaging modalities, tissue and sonication fluid sampling, molecular biology techniques, and histopathological examination. Second, recommendations on microbiology specimen sampling and laboratory operating procedures relevant to FRI will be provided.

Level of Evidence:

Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

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Most cited references 65

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Sonication of removed hip and knee prostheses for diagnosis of infection.

Andrej Trampuz, Kerryl E. Piper, Melissa Jacobson … (2007)

Culturing of samples of periprosthetic tissue is the standard method used for the microbiologic diagnosis of prosthetic-joint infection, but this method is neither sensitive nor specific. In prosthetic-joint infection, microorganisms are typically present in a biofilm on the surface of the prosthesis. We hypothesized that culturing of samples obtained from the prosthesis would improve the microbiologic diagnosis of prosthetic-joint infection. We performed a prospective trial comparing culture of samples obtained by sonication of explanted hip and knee prostheses to dislodge adherent bacteria from the prosthesis with conventional culture of periprosthetic tissue for the microbiologic diagnosis of prosthetic-joint infection among patients undergoing hip or knee revision or resection arthroplasty. We studied 331 patients with total knee prostheses (207 patients) or hip prostheses (124 patients); 252 patients had aseptic failure, and 79 had prosthetic-joint infection. With the use of standardized nonmicrobiologic criteria to define prosthetic-joint infection, the sensitivities of periprosthetic-tissue and sonicate-fluid cultures were 60.8% and 78.5% (P<0.001), respectively, and the specificities were 99.2% and 98.8%, respectively. Fourteen cases of prosthetic-joint infection were detected by sonicate-fluid culture but not by prosthetic-tissue culture. In patients receiving antimicrobial therapy within 14 days before surgery, the sensitivities of periprosthetic tissue and sonicate-fluid culture were 45.0% and 75.0% (P<0.001), respectively. In this study, culture of samples obtained by sonication of prostheses was more sensitive than conventional periprosthetic-tissue culture for the microbiologic diagnosis of prosthetic hip and knee infection, especially in patients who had received antimicrobial therapy within 14 days before surgery. Copyright 2007 Massachusetts Medical Society.

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

W Metsemakers, M. Scarborough, S Kates … (2018)

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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MALDI-TOF MS for the diagnosis of infectious diseases.

Robin Patel (2015)

First introduced into clinical microbiology laboratories in Europe, MALDI-TOF MS is being rapidly embraced by laboratories around the globe. Although it has multiple applications, its widespread adoption in clinical microbiology relates to its use as an inexpensive, easy, fast, and accurate method for identification of grown bacteria and fungi based on automated analysis of the mass distribution of bacterial proteins.

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Author and article information

Journal

Journal ID (nlm-ta): J Orthop Trauma

Journal ID (iso-abbrev): J Orthop Trauma

Journal ID (publisher-id): jot

Title: Journal of Orthopaedic Trauma

Publisher: Journal of Orthopaedic Trauma

ISSN (Print): 0890-5339

ISSN (Electronic): 1531-2291

Publication date (Print): January 2020

Publication date (Electronic): 08 August 2019

Volume: 34

Issue: 1

Pages: 8-17

Affiliations

[* ]Department of Trauma Surgery, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands;

[† ]Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland;

[‡ ]The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom;

[§ ]Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany;

[║ ]Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland;

[¶ ]Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN;

[** ]Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; and

[†† ]Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.

Author notes

Reprints: Willem-Jan Metsemakers, MD, PhD, Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium (e-mail: willem-jan.metsemakers@ 123456uzleuven.be ).

Article

Publisher ID: JOT-2019-57 Accession ID: 00003

DOI: 10.1097/BOT.0000000000001614

PMC ID: 6903359

PubMed ID: 31855973

SO-VID: b908718c-1714-41d0-afbc-2c48da37d57f

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

History

Date accepted : 09 August 2019

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Keywords: fracture-related infection,diagnosis,diagnostic criteria,definition,clinical criteria,medical imaging,histopathology,microbiology,serum inflammatory markers,fracture,infection

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Keywords: fracture-related infection, diagnosis, diagnostic criteria, definition, clinical criteria, medical imaging, histopathology, microbiology, serum inflammatory markers, fracture, infection

Diagnosing Fracture-Related Infection: Current Concepts and Recommendations

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Abstract

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Most cited references 65

Sonication of removed hip and knee prostheses for diagnosis of infection.

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

MALDI-TOF MS for the diagnosis of infectious diseases.

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