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

Martin McNally; Ruth Corrigan; Jonathan Sliepen; Maria Dudareva; Rob Rentenaar; Frank IJpma; Bridget L Atkins; Marjan Wouthuyzen-Bakker; Geertje Govaert

doi:10.3390/antibiotics11070946

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

Antibiotics (Basel). 2022 Jul 14;11(7):946. doi: 10.3390/antibiotics11070946.

Authors

Martin McNally¹, Ruth Corrigan^{1

2}, Jonathan Sliepen³, Maria Dudareva¹, Rob Rentenaar⁴, Frank IJpma³, Bridget L Atkins¹, Marjan Wouthuyzen-Bakker⁵, Geertje Govaert⁶

Affiliations

¹ Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK.
² Nuffield Department of Clinical Laboratory Sciences, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK.
³ Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands.
⁴ Department of Medical Microbiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands.
⁵ Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands.
⁶ Department of Trauma Surgery, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands.

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.

Keywords: DAIR; fracture; fracture-related infection; infection; local antibiotics; non-union; outcome; timing.

Grants and funding

This research received no external funding.