1 fracture related infection where are we now

Surgical Site Infection CDCSurgical site infection = infection of the incision / organ / space that occur after surgery 5 Source: CDC – National Healthcare Safety Network NHSN 2023... C

INTERDISCIPLINARY CME CONGRESS

Ho Chi Minh City, September 16th, 2023

UNIVERSITY OF MEDICINE & PHARMACY AT HO CHI MINH CITY

Fracture – Related Infection

Where are we now?

Do Phuoc Hung, M.D, Assoc.Prof.

Department of Orthopaedics and Rehabilitations

Why are we here? What’s the matter?!

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How significant is definition of FRI?

• Accurate diagnosis: critical for preventing poor outcomes

• Limitations with gold standards: further complicate diagnosis and management process

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Which condition does

‘Fracture – Related Infection’ (FRI)

most likely refer to?

A Surgical Site Infection (SSI)

B Infected Nonunion/Septic Nonunion

C Infection After Fracture Fixation

D Posttraumatic Osteomyelitis

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Surgical Site Infection (CDC)

Surgical site infection = infection of the incision / organ / space

that occur after surgery

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Source: CDC – National Healthcare Safety Network (NHSN) 2023

Diagnostic Criteria – SSI

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NHSN orthopedic procedure

only ORIF

• > 90 days?

• Other procedures than ORIF? No surgery?

Source: CDC – National Healthcare Safety Network (NHSN) 2023

“ a more comprehensive term encompassed infections with and without implants

& included infection of all parts of the bone (cortical, medullary, epiphyseal).”

– Haematogenous infection arising after fx healing (?)

Source: Metsemakers et al Injury 2018;49(3):505-510 McNally et al EFORT Open Rev 2020;5(10):614–619

Case presentation

• Male, 23 years old

• ORIF right proximal humerus fx 6 months ago

• Swelling, warm, redness, painful scar for 1 month,

unconfirmed purulent drainage, fever (-)

• Exam: tenderness (+), restricted shoulder ROM

• WBC 8.32 G/L, Neu 58.7%, CRP 13.1 mg/L

Can FRI be diagnosed at this time?

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Clinical Diagnosis – FRI

Note: presence of pathogens via

culture is NOT an absolute

requirement, esp in chronic

antibiotic-use cases

Source: Govaert et al J Orthop Trauma 2020;34:8-17

Case presentation

• Male, 23 years old

• ORIF right proximal humerus fx 6 months ago

• Swelling, warm, redness, painful scar for 1 month,

unconfirmed purulent drainage, fever (-)

• Exam: tenderness (+), restricted shoulder ROM

• WBC 8.32 G/L, Neu 58.7%, CRP 13.1 mg/L

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How can we confirmed the communication

between the infection & fracture/implant?

Aspiration? Operation? or Else?

Clinical Diagnosis – FRI

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Clinical signs

Local: swelling /  temperature /

redness / pain (without weight

bearing,  over time, new)

Persistent /  / new wound

drainage (beyond first few days

postop, without explanation)

New joint effusion in fracture

patients (implant penetrates joint

capsule / intra-articular fractures)

Systemic: fever (≥ 38.3 o C)

Suggestive Criteria ≥ 1

Source: Govaert et al J Orthop Trauma 2020;34:8-17

Swelling 2m after ORIF femur fx

Swelling 2m after ORIF patella fx New discharge 2 wks

after ORIF tibia fx

Clinical Diagnosis – FRI

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Laboratory signs

Only in case of secondary rise

(after initial decrease) or

consistent elevation over time

AND after exclusion other infectious focci or inflammation processes

Insufficient to confirm or rule out Cautious when interpreting results

Source: Govaert et al J Orthop Trauma 2020;34:8-17 van den Kieboom et al Bone Joint J 2018;100-B:1542-1550

Clinical Diagnosis – FRI

Sequestration (occurring over time)

Failure of progression of bone

healing (non-union)

Periosteal bone formation (≠

fracture site / in case of a

Come back to the case

• Male, 23 years old

• ORIF right proximal humerus fx 6 months ago

• Swelling, warm, redness, painful scar for 1 month,

unconfirmed purulent drainage, fever (-)

• Exam: tenderness (+), restricted shoulder ROM

Diagnostic Flowchart

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Source: Govaert et al J Orthop Trauma 2020;34:8-17

Post-op Diagnosis – FRI

neutrophils via high-power field (Govaert et al, 2020)

Preferably 5 samples:

• Ideally from implant – bone interface

• Avoid superficial, skin, or sinus tract samples

• By separate clean, unused instruments

• ‘No touch’ the skin

• Put in separate pieces of gauze

• Transferred in separate containers

Source: Govaert et al J Orthop Trauma 2020;34:8-17

Post-op Diagnosis – FRI

Only in chronic / late-onset cases (nonunion)

Source: Govaert et al J Orthop Trauma 2020;34:8-17 Morgenstern et al Bone Joint J 2018;100-B:966–972

Post-op Diagnosis – FRI

Culture: pathogenic organism from

a single deep tissue / implant

specimen

Suggestive Criteria

Source: Govaert et al J Orthop Trauma 2020;34:8-17

The patient underwent surgery

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Source: Onsea et al Injury 2022;53(6):1867-1879

Timing Classification of IAFF

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• Early (< 2 weeks):

– Highly virulent organism

– Biofilm: may ‘immature’

– Bone: ‘inflammatory’ or ‘soft callus’

• Delayed (2 – 10 weeks):

– Less virulent organism

– Biofilm: ‘mature’, more resistant

– Bone: ‘hard callus’

• Late (> 10 weeks):

– Low virulent organism

– Periosteal new bone formation,

involucrum

Source: Metsemakers et al Injury 2018;49(3):511-522

Classification of Osteomyelitis

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• 12 clinical stages

• Guide treatment strategies

• NO correlate with prognosis

• NO reference to soft tissue coverage & microbiology

Source: Cierny et al Chin Orthop Relat Res 2003;414:7-24

The new BACH Classification

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• High reproducibility

• Can be applied accurately

by users with a variety of clinical backgrounds

• Need further evaluation for prognosis & management

Source: Hotchen et al Bone Joint Res 2019;8(10):459-468

The Joint-Specific BACH classification

Everything is not perfect !

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• Lack of evidence regarding value &

validity of parameters for diagnostic

criteria

• Definition based on consensus of

small group of experts

However, the definition:

• Offers opportunity to standardize clinical reports &  quality of published literature

• Leads to a standardized clinical approach toward diagnostic workup of patients

with suspected FRI

Meeting of 35 experts on diagnosis for FRI in 2018

(AO Foundation)

Source: Govaert et al J Orthop Trauma 2020;34:8-17

FUTURE DIRECTIONS FOR CLINICAL MICROBIOLOGY FRI DIAGNOSTICS

• Optimized culture techniques

• Molecular diagnostics

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Take–home messages

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• Fracture – Related Infections = all infections occur in the

presence of a fracture

• FRI diagnosis is a step-wise approach, based on

confirmatory criteria & suggestive criteria

• FRI classification should involve the timing, extent of bone

involvement, host status, microbiology & soft tissue coverage