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Fracture-related infection (FRI) is a devastating event, directly affecting fracture healing, impairing patient function, prolonging treatment, and increasing healthcare costs. Time plays a decisive role in prognosis, as biofilm maturation leads to the development of antibiotic resistance, potentially contributing to infection chronicity and increasing morbidity and mortality. Research exploring the association between biofilm maturation and antibiotic resistance in orthopaedics primarily addresses aspects related to quality of life and physical function; however, little exists on life-threatening conditions and mortality. Understanding the intrinsic relationship between biofilm maturation, bacterial resistance, and mortality is critical in all fields of medicine. In the herein narrative review, we summarize recent evidence regarding biofilm formation, antibiotic resistance, and infection chronicity (BARI), the three basic components of the "triangle of death" of FRI, and its implications. Preoperative, perioperative, and postoperative prevention strategies to avoid the "triangle of death" of FRI are presented and discussed. Additionally, the importance of the orthopaedic trauma surgeon in understanding new tools to combat infections related to orthopaedic devices is highlighted. [ABSTRACT FROM AUTHOR]

Prevention of fracture-related infection (FRI) remains a substantial challenge in orthopaedic trauma care. There is evolving evidence to support the use of local antibiotics for both the prevention and treatment of musculoskeletal infection. Local antibiotics can achieve higher local tissue concentrations with a lower risk of systemic complications compared to intravenously administered antibiotics. These antibiotics may be administered in powder or liquid form without carrier, or if sustained release is desired, using a carrier. Polymethylmethacrylate (PMMA), ceramics, and hydrogels are examples of antibiotic carriers. Unlike PMMA, ceramics and hydrogels have the advantage of not requiring a second surgery for removal. The VANCO trial supported the use of powdered vancomycin in high-risk fracture cases for the reduction of Gram-positive infections; although, data is limited. Future studies will evaluate the use of aminoglycoside antibiotics to address Gram-negative infection prevention. While theoretical concerns exist with the use of local antibiotics, available studies suggest local antibiotics are safe with a low-risk of adverse effects.

Background: The management of pelvic fractures is a significant challenge. Surgical site infection can result in the need for revision surgery, cause functional impairment, and lead to a prolonged length of stay and increased treatment costs. Although reports on fracture-related infection (FRI) after pelvic fracture fixation are sparsely reported in the literature, it is a serious complication. This study analysed patients with FRIs after pelvic fracture regarding patient characteristics, treatment strategies, and an evaluation of risk factors for FRI. Methods: In this retrospective single-centre study, FRI was diagnosed based on clinical symptoms of infection and a positive culture of a bacterial infection. Depending on the severity and acuteness of the infection, osseous stabilization was restored either via implant retention (stable implant, no osteolysis), exchange (loose implant or bony defect), or external fixation (recurrence of infection after prior implant retaining revision). Healing of infection was defined as no sign of recurring infection upon clinical, radiological, and laboratory examination in the last follow-up visit. Results: The FRI rate in our patient population was 7.5% (24/316). In 8/24 patients, the FRI occurred within the first three weeks after initial surgery (early) and 16/24 presented with a late onset of symptoms of FRI. A strategy of debridement, antibiotics, and implant retention (DAIR) was successful in 9/24 patients with FRI after pelvic fracture. A total of 10 patients required an exchange of osteo-synthetic implants, whereof three were exchanged to an external fixator. In five patients, we removed the implant because the fracture had already consolidated at the time of revision for infection. A total of 17/24 patients had a poly-microbial infection after a pelvic fracture and 3/24 patients died from post-traumatic multi-organ failure within the first 6 months after trauma. There were no cases of persistent infection within the remaining 21 patients. Conclusions: Although poly-microbial infection is common in FRI after pelvic fracture, the recurrence rate of infection is relatively low. A complex pelvic trauma with significant soft tissue injury is a risk factor for recurrent infection and multiple revisions. A strategy of DAIR can be successful in patients with a stable implant. In cases with recurrent infection or an unstable fracture site, the exchange of implants should be considered. [ABSTRACT FROM AUTHOR]

Introduction: Fracture-related infections (FRI) and periprosthetic joint infections (PJI) represent a major challenge in orthopedic surgery. Incidence of both entities is annually growing. Comorbidities play an important role as an influencing factor for infection and thus, for prevention and treatment strategies. The aims of this study were (1) to analyze the frequency of comorbidities in FRI and PJI patients and (2) to evaluate comorbidities as causative risk factor for PJI and FRI. Methods: This retrospective cohort study analysed all ICD-10 codes, which were coded as secondary diagnosis in all in hospital-treated FRI and PJI in the year 2019 in Germany provided by the Federal Statistical Office of Germany (Destatis). Prevalence of comorbidities was compared with the prevalence in the general population. Results: In the year 2019, 7158 FRIs and 16,174 PJIs were registered in Germany, with 68,304 comorbidities in FRI (mean: 9.5 per case) and 188,684 in PJI (mean: 11.7 per case). Major localization for FRI were infections in the lower leg (55.4%) and forearm (9.2%), while PJI were located mostly at hip (47.4%) and knee joints (45.5%). Mainly arterial hypertension (FRI: n = 3645; 50.9%—PJI: n = 11360; 70.2%), diabetes mellitus type II (FRI: n = 1483; 20.7%—PJI: n = 3999; 24.7%), obesity (FRI: n = 749; 10.5%—PJI: n = 3434; 21.2%) and chronic kidney failure (FRI: n = 877; 12.3%—PJI: n = 3341; 20.7%) were documented. Compared with the general population, an increased risk for PJI and FRI was reported in patients with diabetes mellitus (PJI: 2.988; FRI: 2.339), arterial hypertension (PJI: 5.059; FRI: 2.116) and heart failure (PJI: 6.513; FRI: 3.801). Conclusion: Patients with endocrinological and cardiovascular diseases, in particular associated with the metabolic syndrome, demonstrate an increased risk for orthopedic implant related infections. Based on the present results, further infection prevention and treatment strategies should be evaluated. [ABSTRACT FROM AUTHOR]