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What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

Authors/contributors
Abstract
This international, multi-center study investigated the effect of individual components of surgery on the clinical outcomes of patients treated for fracture-related infection (FRI). All patients with surgically treated FRIs, confirmed by the FRI consensus definition, were included. Data were collected on demographics, time from injury to FRI surgery, soft tissue reconstruction, stabilization and systemic and local anti-microbial therapy. Patients were followed up for a minimum of one year. In total, 433 patients were treated with a mean age of 49.7 years (17–84). The mean follow-up time was 26 months (range 12–72). The eradication of infection was successful in 86.4% of all cases and 86.0% of unhealed infected fractures were healed at the final review. In total, 3.3% required amputation. The outcome was not dependent on age, BMI, the presence of metalwork or time from injury (recurrence rate 16.5% in FRI treated at 1–10 weeks after injury; 13.1% at 11–52 weeks; 12.1% at >52 weeks: p = 0.52). The debridement and retention of a stable implant (DAIR) had a failure rate of 21.4%; implant exchange to a new internal fixation had a failure rate of 12.5%; and conversion to external fixation had a failure rate of 10.3% (adjusted hazard ratio (aHR) DAIR vs. Ext Fix 2.377; 95% C.I. 0.96–5.731). Tibial FRI treated with a free flap was successful in 92.1% of cases and in 80.4% of cases without a free flap (HR 0.38; 95% C.I. 0.14–1.0), while the use of NPWT was associated with higher recurrence rates (HR 3.473; 95% C.I. 1.852–6.512). The implantation of local antibiotics reduced the recurrence from 18.7% to 10.0% (HR 0.48; 95% C.I. 0.29–0.81). The successful treatment of FRI was multi-factorial. These data suggested that treatment decisions should not be based on time from injury alone, as other factors also affected the outcome. Further work to determine the best indications for DAIR, free flap reconstruction and local antibiotics is warranted.
Publication
Antibiotics
Date
2022-07-14
Notes

Key Questions:

  • What factors affect outcomes in the treatment of fracture-related infections (FRIs)?
  • Do the traditional time categorizations for early vs delayed vs late FRIs accurately predict treatment outcomes?

Key Findings:

  • Successful FRI treatment was associated with smoking cessation, avoiding delayed wound closure with NPWT, using flap reconstruction for complex tibial wounds, and locally implanting antibiotics.
  • FRI outcomes were not dependent on time from injury, BMI, presence of implants, or age.
  • DAIR had a higher failure rate than implant exchange or conversion to external fixation, but time from injury did not affect DAIR outcomes.

Clinical Implications:

  • Treatment decisions for FRIs should consider multiple factors beyond just time from injury.
  • DAIR remains an acceptable option for many patients if closely monitored, though outcomes are worse than other options.
  • Smoking cessation, limiting NPWT, flap reconstruction for tibias, and local antibiotics may improve FRI treatment.

Strengths:

  • Large multi-center cohort of 433 FRIs with thorough data collection
  • Used standard FRI definition and clear criteria for treatment failure
  • Evaluated real-world outcomes across range of FRI treatments

Limitations:

  • Observational study with potential confounding factors
  • Heterogeneous population and treatments limit analysis of specific therapies
  • Single-country sample may limit generalizability

Level of Evidence Assessment: Moderate

Rationale: This is a well-designed and executed observational cohort study. The level of evidence would be considered moderate on the GRADE scale given the observational design, but is strengthened by the large sample size, multi-center recruitment, and rigorous data analysis. The results are likely valid but further confirmation in experimental trials is warranted.

Citation
1.
McNally M, Corrigan R, Sliepen J, et al. What Factors Affect Outcome in the Treatment of Fracture-Related Infection? Antibiotics. 2022;11(7):946.