Pub Date : 2024-11-01DOI: 10.1016/j.injury.2024.111845
Fracture related infection (FRI) remains one of the most challenging complications of orthopaedic trauma surgery. Several factors contribute to FRI development but, among those, particularly interesting from the orthopaedic surgeon's perspective is the contribution of mechanical stability and timing of fracture fixation. These are indeed crucial factors both in prevention and treatment of FRI and are directly influenced by the surgeon's work. While the role of stability has been studied and discussed, the pathophysiological process regulating such role and how this influences surgeon's treatment decision making is still debated. The same applies to the ideal timing of temporary or definitive fixation which varies according to the clinical scenario considered.
In the present narrative review, we described the influence of mechanical stability on both FRI pathophysiology and on the decision making of FRI treatment. In addition, we analysed the impact of the timing of fracture fixation on the risk of FRI development particularly in those clinical scenarios where it has been shown to be specifically relevant, such as fractures affecting segments with poor soft tissue envelope, open fractures, damage control orthopaedics, and the need for soft tissue coverage.
{"title":"Effect of mechanical stability of osteosynthesis on infection rates: Timing of temporary and definitive fixation","authors":"","doi":"10.1016/j.injury.2024.111845","DOIUrl":"10.1016/j.injury.2024.111845","url":null,"abstract":"<div><div>Fracture related infection (FRI) remains one of the most challenging complications of orthopaedic trauma surgery. Several factors contribute to FRI development but, among those, particularly interesting from the orthopaedic surgeon's perspective is the contribution of mechanical stability and timing of fracture fixation. These are indeed crucial factors both in prevention and treatment of FRI and are directly influenced by the surgeon's work. While the role of stability has been studied and discussed, the pathophysiological process regulating such role and how this influences surgeon's treatment decision making is still debated. The same applies to the ideal timing of temporary or definitive fixation which varies according to the clinical scenario considered.</div><div>In the present narrative review, we described the influence of mechanical stability on both FRI pathophysiology and on the decision making of FRI treatment. In addition, we analysed the impact of the timing of fracture fixation on the risk of FRI development particularly in those clinical scenarios where it has been shown to be specifically relevant, such as fractures affecting segments with poor soft tissue envelope, open fractures, damage control orthopaedics, and the need for soft tissue coverage.</div></div>","PeriodicalId":54978,"journal":{"name":"Injury-International Journal of the Care of the Injured","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142553686","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.injury.2024.111823
Fracture-related infections are significant postoperative complications that carry substantial patient burden and additional healthcare costs. Despite their impact on outcome, early diagnosis of these infections remains challenging due to current available tests lacking acceptable diagnostic parameters. This review compiles existing information on blood-based biomarkers that have been evaluated as early diagnostic tools and highlights the challenges in their reliability. To begin to overcome these challenges new avenues of biomarker discovery utilizing “omics” technologies and novel analytical methods are being investigated in recent years. It appears that, despite their complexity, these newer approaches may be the future in biomarker discovery for fracture-related infection diagnosis.
{"title":"Fracture-related infection blood-based biomarkers: Diagnostic strategies","authors":"","doi":"10.1016/j.injury.2024.111823","DOIUrl":"10.1016/j.injury.2024.111823","url":null,"abstract":"<div><div>Fracture-related infections are significant postoperative complications that carry substantial patient burden and additional healthcare costs. Despite their impact on outcome, early diagnosis of these infections remains challenging due to current available tests lacking acceptable diagnostic parameters. This review compiles existing information on blood-based biomarkers that have been evaluated as early diagnostic tools and highlights the challenges in their reliability. To begin to overcome these challenges new avenues of biomarker discovery utilizing “omics” technologies and novel analytical methods are being investigated in recent years. It appears that, despite their complexity, these newer approaches may be the future in biomarker discovery for fracture-related infection diagnosis.</div></div>","PeriodicalId":54978,"journal":{"name":"Injury-International Journal of the Care of the Injured","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142010130","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.injury.2024.111959
{"title":"Editorial: Fracture-related infections","authors":"","doi":"10.1016/j.injury.2024.111959","DOIUrl":"10.1016/j.injury.2024.111959","url":null,"abstract":"","PeriodicalId":54978,"journal":{"name":"Injury-International Journal of the Care of the Injured","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142553734","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/S0020-1383(24)00721-6
{"title":"Front Matter 1 - Full Title Page (regular issues)/Special Issue Title page (special issues)","authors":"","doi":"10.1016/S0020-1383(24)00721-6","DOIUrl":"10.1016/S0020-1383(24)00721-6","url":null,"abstract":"","PeriodicalId":54978,"journal":{"name":"Injury-International Journal of the Care of the Injured","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142553858","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.injury.2024.111862
Although fracture-related infection (FRI) is a serious complication following bone fractures, a comprehensive definition and diagnostic criteria have only emerged in recent years. According to this consensus definition, the diagnosis of FRI is based on preoperative and intraoperative suggestive or confirmatory criteria. Serum markers, histology, and microbiological cultures are considered to play a crucial role in the FRI diagnostic pathway. However, at the time of publication of the FRI consensus definition in 2018 and its update in 2020, limited data was available on the accuracy of these diagnostic methods. This review aims to provide an overview of recent publications and discuss whether new evidence has been obtained regarding the value of these current diagnostic techniques.
Meanwhile, several studies have confirmed the limited prognostic value of C-reactive protein, erythrocyte sedimentation ratio, and white blood cell count. Other serologic markers for preoperative diagnosis of FRI with promising diagnostic performance are d-dimer, plasma fibrinogen, platelet count to mean platelet volume ratio, and a risk prediction model that includes soft tissue injury type and fracture complexity in addition to blood markers. However, their true diagnostic value in daily clinical practice needs to be investigated in further studies. Data on histology in FRI diagnosis is still limited, but its potential as a confirmatory criterion seems to lie in its high specificity. Recent studies indicate that tissue culture exhibits moderate sensitivity and high specificity, with sensitivity improvements achieved by sampling of five specimens and long-term culture. Implant sonication also appears to enhance the sensitivity of culture and the detection rate of polymicrobial infections.
In conclusion, the true value of diagnostic techniques is difficult to assess, in part because it is measured against a gold standard that is itself imperfect and still evolving, but also because of methodological differences in sample processing or the use of different thresholds. Nevertheless, this review has identified that the value of current diagnostic techniques is high when used in combination. To draw more accurate conclusions about the value of serum markers, histology, and culture including sonication, future studies should be prospective and utilize a greater standardization in sampling and methodological protocols.
{"title":"The value of current diagnostic techniques in the diagnosis of fracture-related infections: Serum markers, histology, and cultures","authors":"","doi":"10.1016/j.injury.2024.111862","DOIUrl":"10.1016/j.injury.2024.111862","url":null,"abstract":"<div><div>Although fracture-related infection (FRI) is a serious complication following bone fractures, a comprehensive definition and diagnostic criteria have only emerged in recent years. According to this consensus definition, the diagnosis of FRI is based on preoperative and intraoperative suggestive or confirmatory criteria. Serum markers, histology, and microbiological cultures are considered to play a crucial role in the FRI diagnostic pathway. However, at the time of publication of the FRI consensus definition in 2018 and its update in 2020, limited data was available on the accuracy of these diagnostic methods. This review aims to provide an overview of recent publications and discuss whether new evidence has been obtained regarding the value of these current diagnostic techniques.</div><div>Meanwhile, several studies have confirmed the limited prognostic value of C-reactive protein, erythrocyte sedimentation ratio, and white blood cell count. Other serologic markers for preoperative diagnosis of FRI with promising diagnostic performance are d-dimer, plasma fibrinogen, platelet count to mean platelet volume ratio, and a risk prediction model that includes soft tissue injury type and fracture complexity in addition to blood markers. However, their true diagnostic value in daily clinical practice needs to be investigated in further studies. Data on histology in FRI diagnosis is still limited, but its potential as a confirmatory criterion seems to lie in its high specificity. Recent studies indicate that tissue culture exhibits moderate sensitivity and high specificity, with sensitivity improvements achieved by sampling of five specimens and long-term culture. Implant sonication also appears to enhance the sensitivity of culture and the detection rate of polymicrobial infections.</div><div>In conclusion, the true value of diagnostic techniques is difficult to assess, in part because it is measured against a gold standard that is itself imperfect and still evolving, but also because of methodological differences in sample processing or the use of different thresholds. Nevertheless, this review has identified that the value of current diagnostic techniques is high when used in combination. To draw more accurate conclusions about the value of serum markers, histology, and culture including sonication, future studies should be prospective and utilize a greater standardization in sampling and methodological protocols.</div></div>","PeriodicalId":54978,"journal":{"name":"Injury-International Journal of the Care of the Injured","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142304840","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.injury.2024.111842
Animal models are essential for orthopedic infectious research. However, only few models are currently able to capture the complex and multidisciplinary treatment approach for osteomyelitis. To replicate treatment situations in their entirety, large animal models are needed, and the most used species are sheep and pigs. Herein, we review a well-characterized and reproducible porcine model of human-scale one-stage revision of implant-associated osteomyelitis that can be used for robust preclinical testing of operative and post-operative interventions. The pros and cons of the model are discussed in the context of existing literature on large animal revision models.
{"title":"In vivo models of infection: Large animals – Mini review on human-scale one-stage revision in a porcine osteomyelitis model","authors":"","doi":"10.1016/j.injury.2024.111842","DOIUrl":"10.1016/j.injury.2024.111842","url":null,"abstract":"<div><div>Animal models are essential for orthopedic infectious research. However, only few models are currently able to capture the complex and multidisciplinary treatment approach for osteomyelitis. To replicate treatment situations in their entirety, large animal models are needed, and the most used species are sheep and pigs. Herein, we review a well-characterized and reproducible porcine model of human-scale one-stage revision of implant-associated osteomyelitis that can be used for robust preclinical testing of operative and post-operative interventions. The pros and cons of the model are discussed in the context of existing literature on large animal revision models.</div></div>","PeriodicalId":54978,"journal":{"name":"Injury-International Journal of the Care of the Injured","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142553685","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.injury.2024.111977
This narrative review discusses treatment strategies and key considerations guiding decisions in the surgical management of fracture-related infections (FRI). Treatment options primarily revolve around two approaches: debridement antibiotics and implant retention (DAIR), or implant exchange, either in a one or multiple-stage strategy. Several considerations, including time since infection onset, implant type, stability, causative pathogens, host physiology, and soft tissue conditions, inform the choice of surgical intervention for FRI. Current literature supports the preference for a DAIR approach in cases with a short duration of ongoing symptoms, a stable implant with satisfactory fracture reduction, and a viable soft tissue envelope. Conversely, one- or multiple-stage implant exchange is deemed beneficial in instances of compromised local and systemic host physiology, mature biofilm, difficult-to-treat pathogens, intramedullary implants, and cases involving reinfections or failed DAIR procedures. Notably, these recommendations draw parallels from periprosthetic joint infection treatment strategies, constrained by the limited availability of randomized controlled trials comparing these options specifically in acute FRI. In conclusion, future perspectives call for extensive investigations into biofilm maturation and the impact of time on treatment outcomes. Additionally, there is a need for a standardized classification system for FRI to enhance the comparability of treatment outcomes in FRI management.
这篇叙述性综述讨论了骨折相关感染（FRI）手术治疗的治疗策略和主要考虑因素。治疗方案主要围绕两种方法：清创抗生素和植入物保留（DAIR）或植入物交换，可采用一个或多个阶段的策略。在选择 FRI 的手术治疗方法时要考虑多个因素，包括感染发生后的时间、种植体类型、稳定性、致病病原体、宿主生理学和软组织条件。目前的文献支持在症状持续时间短、植入物稳定、骨折复位满意、软组织包膜可行的病例中首选 DAIR 方法。相反，在局部和全身宿主生理学受损、生物膜成熟、病原体难以治疗、髓内植入物以及涉及再感染或 DAIR 手术失败的病例中，单阶段或多阶段植入物交换被认为是有益的。值得注意的是，这些建议借鉴了假体周围关节感染治疗策略，但受限于专门针对急性 FRI 的随机对照试验比较方案有限。总之，从未来的角度来看，需要对生物膜的成熟和时间对治疗效果的影响进行广泛研究。此外，还需要为 FRI 建立标准化的分类系统，以提高 FRI 治疗结果的可比性。
{"title":"The DAIR-procedure in fracture-related infection–When and how","authors":"","doi":"10.1016/j.injury.2024.111977","DOIUrl":"10.1016/j.injury.2024.111977","url":null,"abstract":"<div><div>This narrative review discusses treatment strategies and key considerations guiding decisions in the surgical management of fracture-related infections (FRI). Treatment options primarily revolve around two approaches: debridement antibiotics and implant retention (DAIR), or implant exchange, either in a one or multiple-stage strategy. Several considerations, including time since infection onset, implant type, stability, causative pathogens, host physiology, and soft tissue conditions, inform the choice of surgical intervention for FRI. Current literature supports the preference for a DAIR approach in cases with a short duration of ongoing symptoms, a stable implant with satisfactory fracture reduction, and a viable soft tissue envelope. Conversely, one- or multiple-stage implant exchange is deemed beneficial in instances of compromised local and systemic host physiology, mature biofilm, difficult-to-treat pathogens, intramedullary implants, and cases involving reinfections or failed DAIR procedures. Notably, these recommendations draw parallels from periprosthetic joint infection treatment strategies, constrained by the limited availability of randomized controlled trials comparing these options specifically in acute FRI. In conclusion, future perspectives call for extensive investigations into biofilm maturation and the impact of time on treatment outcomes. Additionally, there is a need for a standardized classification system for FRI to enhance the comparability of treatment outcomes in FRI management.</div></div>","PeriodicalId":54978,"journal":{"name":"Injury-International Journal of the Care of the Injured","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142553926","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.injury.2024.111712
Introduction
The diagnosis of low-grade infection in post-traumatic long bone non-unions poses challenges due to the absence of clinical signs. This study aimed to review the available literature on the diagnostic accuracy of imaging techniques for low-grade infections and assess the diagnostic accuracy of 18F-FDG PET-CT scans for low-grade infection in post-traumatic long bone non-unions.
Methods
A mini-review was conducted using Pubmed in March 2024. A retrospective study was conducted including adult patients with a long bone non-union, suspected of infection. All patients underwent 18F-FDG PET-CT scans as the index test before surgical intervention, with peri‑operative cultures obtained during surgery serving as the reference standard. Quantitative analyses were performed on the standardized uptake value (SUV) measurements obtained from the 18F-FDG PET-CT scans. Diagnostic accuracy measures including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Receiver operating characteristic (ROC) curve analysis was employed to evaluate the discriminatory ability of SUV measurements.
Results
Literature suggests that 18F-FDG PET-CT is the most accurate imaging technique to detect low-grade infections. The study included a total of 51 18F-FDG PET-CT scans and cultures from 50 patients with long bone non-unions. The diagnostic accuracy was found to be 0.67 (95 % CI 0.44–0.87). The PPV and NPV were calculated as 0.79 (95 % CI 0.53–1.00) and 0.52 (95 % CI 0.30–0.73), respectively. Quantitative analyses of SUV measurements demonstrated a low level of accuracy, with all area under the curve (AUC) values < 0.75 and ROC curves showing a trajectory fairly parallel to the diagonal line.
Conclusion and discussion
The findings of this study indicate that in post-traumatic long bone non-unions, where a low-grade fracture-related infection (FRI) is suspected, the 18F-FDG PET-CT has a performance that is advantageous over other imaging techniques. A careful interpretation of the scan results is warranted, possibly including the quantitative analysis on tracer uptake as an adjunct. Nevertheless, the diagnostic accuracy in this condition is not as good as in early-onset FRI cases, and this should be taken into account when treating these challenging cases.
{"title":"Assessing diagnostic accuracy: 18F-FDG PET-CT scans in low-grade infection detection among post-traumatic long bone non-unions; a literature review and clinical data","authors":"","doi":"10.1016/j.injury.2024.111712","DOIUrl":"10.1016/j.injury.2024.111712","url":null,"abstract":"<div><h3>Introduction</h3><div>The diagnosis of low-grade infection in post-traumatic long bone non-unions poses challenges due to the absence of clinical signs. This study aimed to review the available literature on the diagnostic accuracy of imaging techniques for low-grade infections and assess the diagnostic accuracy of <sup>18</sup>F-FDG PET-CT scans for low-grade infection in post-traumatic long bone non-unions.</div></div><div><h3>Methods</h3><div>A mini-review was conducted using Pubmed in March 2024. A retrospective study was conducted including adult patients with a long bone non-union, suspected of infection. All patients underwent <sup>18</sup>F-FDG PET-CT scans as the index test before surgical intervention, with peri‑operative cultures obtained during surgery serving as the reference standard. Quantitative analyses were performed on the standardized uptake value (SUV) measurements obtained from the <sup>18</sup>F-FDG PET-CT scans. Diagnostic accuracy measures including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Receiver operating characteristic (ROC) curve analysis was employed to evaluate the discriminatory ability of SUV measurements.</div></div><div><h3>Results</h3><div>Literature suggests that <sup>18</sup>F-FDG PET-CT is the most accurate imaging technique to detect low-grade infections. The study included a total of 51 <sup>18</sup>F-FDG PET-CT scans and cultures from 50 patients with long bone non-unions. The diagnostic accuracy was found to be 0.67 (95 % CI 0.44–0.87). The PPV and NPV were calculated as 0.79 (95 % CI 0.53–1.00) and 0.52 (95 % CI 0.30–0.73), respectively. Quantitative analyses of SUV measurements demonstrated a low level of accuracy, with all area under the curve (AUC) values < 0.75 and ROC curves showing a trajectory fairly parallel to the diagonal line.</div></div><div><h3>Conclusion and discussion</h3><div>The findings of this study indicate that in post-traumatic long bone non-unions, where a low-grade fracture-related infection (FRI) is suspected, the <sup>18</sup>F-FDG PET-CT has a performance that is advantageous over other imaging techniques. A careful interpretation of the scan results is warranted, possibly including the quantitative analysis on tracer uptake as an adjunct. Nevertheless, the diagnostic accuracy in this condition is not as good as in early-onset FRI cases, and this should be taken into account when treating these challenging cases.</div></div>","PeriodicalId":54978,"journal":{"name":"Injury-International Journal of the Care of the Injured","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142553921","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.injury.2024.111826
The present minireview aims to provide a context for imagination of the timespan for bone infection evolution from the origin of cellular bone tissue to modern orthopedic surgery. From a phylogenetic osteomyelitis-bracketing perspective, and due to the time of osteocyte origin, bacteria might have been able to infect the skeleton for approximately 400 million years. Thereby, bone infections happened simultaneously with central expansions of the immune system and development of terrestrial bone structure. This co-evolution might aid in explaining the many immune evasion strategies seen in the field of bone infections. Bone infection patients with long disease-free periods followed by sudden recurrence and anamnesis of long-term and low-grade infections indicate that bacteria can perform silent parasitism within bone tissue (parasitism; one organism lives on another organism, the host, causing it harm and is structurally adapted to it). The silence seems to be disturbed by immunosuppression and the present minireview shows that a compromised immune system has been associated with bone infection development across all species in the phylogenetic tree. Orthopedic surgery, including arthroplasty and osteosynthesis, favor introduction of bacteria and prosthesis/implant related infections are thus anthropogenic infections (anthropogenic; resulting from the influence of human beings on nature). In that light it is important to remember that the skeleton and immune system have not evolved for millions of years to protect titanium alloys and other metals, commonly used for orthopedic devices from bacterial invasion. Therefore, these relatively new orthopedic infection types must be seen as distinct with unique implant/prosthesis related pathophysiology and immunology.
{"title":"Bone infection evolution","authors":"","doi":"10.1016/j.injury.2024.111826","DOIUrl":"10.1016/j.injury.2024.111826","url":null,"abstract":"<div><div>The present minireview aims to provide a context for imagination of the timespan for bone infection evolution from the origin of cellular bone tissue to modern orthopedic surgery. From a phylogenetic osteomyelitis-bracketing perspective, and due to the time of osteocyte origin, bacteria might have been able to infect the skeleton for approximately 400 million years. Thereby, bone infections happened simultaneously with central expansions of the immune system and development of terrestrial bone structure. This co-evolution might aid in explaining the many immune evasion strategies seen in the field of bone infections. Bone infection patients with long disease-free periods followed by sudden recurrence and anamnesis of long-term and low-grade infections indicate that bacteria can perform silent parasitism within bone tissue (parasitism; one organism lives on another organism, the host, causing it harm and is structurally adapted to it). The silence seems to be disturbed by immunosuppression and the present minireview shows that a compromised immune system has been associated with bone infection development across all species in the phylogenetic tree. Orthopedic surgery, including arthroplasty and osteosynthesis, favor introduction of bacteria and prosthesis/implant related infections are thus <em>anthropogenic infections</em> (anthropogenic; resulting from the influence of human beings on nature). In that light it is important to remember that the skeleton and immune system have not evolved for millions of years to protect titanium alloys and other metals, commonly used for orthopedic devices from bacterial invasion. Therefore, these relatively new orthopedic infection types must be seen as distinct with unique implant/prosthesis related pathophysiology and immunology.</div></div>","PeriodicalId":54978,"journal":{"name":"Injury-International Journal of the Care of the Injured","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142553735","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.injury.2024.111604
The timely and effective management of open fractures continues to be a challenge in modern orthopaedic practice. Lower limb high energy fractures with complex soft tissue injuries require multi-disciplinary care to achieve the best results. Despite an extensive published literature on open fractures, the timing of debridement and the most appropriate personnel to perform it continue to be a source of debate. National guidelines on the topic are few but they suggest immediate debridement for open fractures with highly contaminated wounds and debridement within 12 to 24 h is considered desirable for less contaminated wounds. There is actually limited evidence linking timing of debridement to infection risk but the largest studies recently published do indicate a link between delay to debridement and increasing infection risk. Most studies on management are based on a clinical model where the initial debridement and fixation are performed by an orthopaedic surgeon and if required delayed coverage and closure is subsequently carried out by a plastic surgeon. More recently, studies have proposed an alternative approach, with initial debridement and temporary fixation followed within 48 h with a further debridement, definitive fixation and flap cover with a combined orthoplastic team. Reported results have been favourable. This is a significant change in management and there are limited data at present to determine if this approach will improve results in the most complex open fractures.
{"title":"Timing of debridement: When to do it, and who should perform it?","authors":"","doi":"10.1016/j.injury.2024.111604","DOIUrl":"10.1016/j.injury.2024.111604","url":null,"abstract":"<div><div>The timely and effective management of open fractures continues to be a challenge in modern orthopaedic practice. Lower limb high energy fractures with complex soft tissue injuries require multi-disciplinary care to achieve the best results. Despite an extensive published literature on open fractures, the timing of debridement and the most appropriate personnel to perform it continue to be a source of debate. National guidelines on the topic are few but they suggest immediate debridement for open fractures with highly contaminated wounds and debridement within 12 to 24 h is considered desirable for less contaminated wounds. There is actually limited evidence linking timing of debridement to infection risk but the largest studies recently published do indicate a link between delay to debridement and increasing infection risk. Most studies on management are based on a clinical model where the initial debridement and fixation are performed by an orthopaedic surgeon and if required delayed coverage and closure is subsequently carried out by a plastic surgeon. More recently, studies have proposed an alternative approach, with initial debridement and temporary fixation followed within 48 h with a further debridement, definitive fixation and flap cover with a combined orthoplastic team. Reported results have been favourable. This is a significant change in management and there are limited data at present to determine if this approach will improve results in the most complex open fractures.</div></div>","PeriodicalId":54978,"journal":{"name":"Injury-International Journal of the Care of the Injured","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142553687","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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