Review Question - QID 219214

This patient presents six weeks after treatment of an open tibia fracture with a draining, purulent wound over the fracture site. A draining sinus tract is confirmatory of a fracture-related infection (FRI) and should prompt surgical wound exploration.

Unfortunately, FRI is a common complication in trauma surgery. Risk factors include both host factors (i.e., diabetes, smoking, and poor vasculature status) and fracture characteristics (i.e., open fracture, soft tissue damage, and fracture location). Research on and diagnosis of FRI has also been limited by a historical lack of a clear definition. In 2018, the AO Foundation and the European Bone and Joint Infection Society (EBJIS) released a consensus position for the diagnosis of FRI. Illustration A shows the proposed algorithm for the diagnosis of FRI. The only preoperative confirmatory clinical signs of FRI are the presence of a fistula, sinus tract, wound breakdown, or purulent drainage. Suggestive criteria for FRI include local clinical signs such as erythema and warmth, as well as systemic signs such as fevers and chills, positive radiological and/or nuclear imaging studies, new onset effusion, and elevated serum inflammatory markers (ESR, CRP, and WBC). A preoperative confirmatory clinical sign should prompt surgical exploration as the next treatment step. Definitive treatment of FRI should involve a multidisciplinary approach.

Metsemakers et al. report on a consensus definition of FRI by the AO Foundation and the EBJIS. The group 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. Furthermore, an expert panel developed a definition based on confirmatory or suggestive criteria. While the authors do not propose a definitive treatment course, they do recommend wound exploration when confirmatory clinical signs are present.

Govaert et al. report on a second consensus meeting including not only experts from the AO Foundation and the EBJIS, but also from the Orthopaedic Trauma Association (OTA) and the PRO-Implant Foundation. They investigated the diagnostic value of clinical parameters, serum inflammatory markers, imaging modalities, tissue and sonication fluid sampling, molecular biology techniques, and histopathological examination. They include illustrations (shown below) that delineate a consensus diagnostic algorithm (Illustration A) and diagnostic recommendations (Illustration B) in the setting of FRI.

Figure 1 shows AP plain films of a left tibia and fibula with a diaphyseal tibia fracture and segmental fibula fracture. Figure 2 shows 6-week post-operative AP plain films with fixation of the tibia diaphyseal fracture using an intramedullary nail. Illustration A shows the proposed diagnostic algorithm from the AO Foundation, EBJIS, OTA, and PRO-Implant Foundation for FRI. Illustration B shows the diagnostic recommendations from the AO Foundation, EBJIS, OTA, and PRO-Implant Foundation for FRI.

Incorrect Answers:
Answer 1: Wound cultures obtained in the clinical setting are not reliable and should not guide definitive treatment plans. Intraoperative deep implant cultures are recommended during surgical exploration.
Answer 2: Oral antibiotics in isolation alone are not an appropriate treatment for FRI. The patient requires surgical wound investigation.
Answer 4: While MRI can be helpful in determining structural anatomy and assist in surgical planning, significant artifact would be expected from the tibial nail and would not change the next best step in management, which should include surgical wound investigation.
Answer 5: Definitive treatment with local wound care is an insufficient treatment method for a confirmed FRI involving deep implants.