1 fracture related infection where are we now

UNIVERSITY OF MEDICINE & PHARMACY AT HO CHI MINH CITY
INTERDISCIPLINARY CME CONGRESS

Fracture – Related Infection
Where are we now?
Do Phuoc Hung, M.D, Assoc.Prof.
Department of Orthopaedics and Rehabilitations

Ho Chi Minh City, September 16th, 2023


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

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

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Diagnostic Criteria – SSI
NHSN orthopedic procedure
only ORIF

• > 90 days?
• Other procedures than ORIF? No surgery?
Source: CDC – National Healthcare Safety Network (NHSN) 2023

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Osteitis or Osteomyelitis?

• Mostly exogenous, but remember
hematogenous!

• Difficult to distinguish
• More important is the presence of

bacteria at fracture site !

Source: Fang et al. J Orthop Surg 2017;25(1):2309499017692712. Depypere et al. Clin Microbiol Infect 2020;26(5):572-578

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What is FRI?
“... a more comprehensive term ... encompassed infections with and without implants
& included infection of all parts of the bone (cortical, medullary, epiphyseal).”

FRI = all infections occur in the

presence of a fracture, including:
– Early infection around fx implants
– Infection in fx with no internal fixation
– Infected nonunion
– 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

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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
Confirmatory Criteria ≥ 1
• Fistula, sinus or wound
breakdown (communication
to bone / implant)

• Purulent drainage or
presence of pus
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

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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

How can we confirmed the communication

between the infection & fracture/implant?
Aspiration? Operation? or Else?
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Clinical Diagnosis – FRI
Suggestive Criteria ≥ 1

New discharge 2 wks
after ORIF tibia fx
Swelling 2m after
ORIF patella fx

Clinical signs
Local: swelling /  temperature /
redness / pain (without weight
bearing,  over time, new)

Persistent /  / new wound

drainage (beyond first few days
postop, without explanation)

Swelling 2m after
ORIF femur fx

New joint effusion in fracture
patients (implant penetrates joint
capsule / intra-articular fractures)
Systemic: fever (≥ 38.3oC)
Source: Govaert et al. J Orthop Trauma 2020;34:8-17

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Clinical Diagnosis – FRI
 BUT ≥ ???
Suggestive Criteria ≥ 1
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
WBC 

• Different cut-offs:
– CRP: 5 – 10 mg/L
– WBC: 9.15 – 10.2 G/L

– ESR: 11 – 30 mm/h

ESR 
CRP 

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

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Clinical Diagnosis – FRI
PO 8m

Suggestive Criteria ≥ 1
Radiological signs
Bone lysis (at fracture, around
implant)
Implant loosening

PO 1 yr

Sequestration (occurring over time)
Failure of progression of bone
healing (non-union)
Periosteal bone formation (≠
fracture site / in case of a
consolidated fracture)

Source: Govaert et al. J Orthop Trauma 2020;34:8-17. Bosch et al. Clin Transl Imaging 2020;8:289-298

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

• Imaging ...

Suggestive criteria (+)  Then, what should we do?

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Diagnostic Flowchart

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

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Post-op Diagnosis – FRI

Confirmatory Criteria ≥ 1
• Culture: phenotypically
indistinguishable pathogens
from ≥ 2 separate deep tissue
/ implant specimens
• Histopathology:
– Microorganisms in deep tissue
specimen

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

– > 5 polymorphonuclear
neutrophils via high-power field
(Govaert et al, 2020)
Source: Govaert et al. J Orthop Trauma 2020;34:8-17

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Post-op Diagnosis – FRI

Implant Sonication

Confirmatory Criteria ≥ 1
• Culture: phenotypically
indistinguishable pathogens
from ≥ 2 separate deep tissue /
implant specimens
• Histopathology:
– Microorganisms in deep tissue

Only in chronic / late-onset cases (nonunion)

specimen
– > 5 polymorphonuclear
neutrophils via high-power
(x400) field (Govaert et al, 2020)
Source: Govaert et al. J Orthop Trauma 2020;34:8-17. Morgenstern et al. Bone Joint J 2018;100-B:966–972

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Post-op Diagnosis – FRI
Suggestive Criteria
In combination with other
suggestive criteria
there should be a high suspicion
of FRI
Culture: pathogenic organism from
a single deep tissue / implant
specimen

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

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The patient underwent surgery

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

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Timing Classification of IAFF
• 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

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Classification of Osteomyelitis
• 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

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The new BACH Classification
• 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

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The Joint-Specific BACH classification

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