Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Jul;141(7):1215-1230.
doi: 10.1007/s00402-020-03525-0. Epub 2020 Aug 29.

Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis

H Bezstarosti  1 , W J Metsemakers  2   3 , E M M van Lieshout  4 , L W Voskamp  4 , K Kortram  4 , M A McNally  5 , L C Marais  6 , M H J Verhofstad  4
Affiliations

Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis

H Bezstarosti et al. Arch Orthop Trauma Surg. 2021 Jul.

Abstract

Purpose: This systematic review determined the reported treatment strategies, their individual success rates, and other outcome parameters in the management of critical-sized bone defects in fracture-related infection (FRI) patients between 1990 and 2018.

Methods: A systematic literature search on treatment and outcome of critical-sized bone defects in FRI was performed. Treatment strategies identified were, autologous cancellous grafts, autologous cancellous grafts combined with local antibiotics, the induced membrane technique, vascularized grafts, Ilizarov bone transport, and bone transport combined with local antibiotics. Outcomes were bone healing and infection eradication after primary surgical protocol and recurrence of FRI and amputations at the end of study period.

Results: Fifty studies were included, describing 1530 patients, the tibia was affected in 82%. Mean age was 40 years (range 6-80), with predominantly male subjects (79%). Mean duration of infection was 17 months (range 1-624) and mean follow-up 51 months (range 6-126). After initial protocolized treatment, FRI was cured in 83% (95% CI 79-87) of all cases, increasing to 94% (95% CI 92-96) at the end of each individual study. Recurrence of infection was seen in 8% (95% CI 6-11) and amputation in 3% (95% CI 2-3). Final outcomes overlapped across treatment strategies.

Conclusion: Results should be interpreted with caution due to the retrospective and observational design of most studies, the lack of clear classification systems, incomplete data reports, potential underreporting of adverse outcomes, and heterogeneity in patient series. A consensus on classification, treatment protocols, and outcome is needed to improve reliability of future studies.

Keywords: Bone transport; Fracture-related infection; Induced membrane technique; Treatment; Vascularized bone graft.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Inclusion flowchart
Fig. 2
Fig. 2
Proportional clinical outcome. Numbers under the X-axis represent the number of studies for which data are pooled; AB local antibiotics
Fig. 3
Fig. 3
Clinical outcome by weighted mean. Numbers under the X-axis represent the number of studies for which data are pooled; AB local antibiotics
See this image and copyright information in PMC

References

    1. Court-Brown CM. Fractures of the tibia and fibula. Philadelphia: Lippincott Williams & Wilkins; 2005.
    1. Bhandari M, Guyatt G, Tornetta P, 3rd, Schemitsch EH, Swiontkowski M, Sanders D, Walter SD. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Jt Surg Am. 2008;90:2567–2578. - PMC - PubMed
    1. Sanders DW, Bhandari M, Guyatt G, Heels-Ansdell D, Schemitsch EH, Swiontkowski M, Tornetta P, 3rd, Walter S, Investigators S. Critical-sized defect in the tibia: is it critical? Results from the SPRINT trial. J Orthop Trauma. 2014;28:632–635. - PubMed
    1. Lovati AB, Romanò CL, Bottagisio M, Monti L, De Vecchi E, Previdi S, Accetta R, Drago L. Modeling staphylococcus epidermidis-induced non-unions: subclinical and clinical evidence in rats. PLoS ONE. 2016 doi: 10.1371/journal.pone.0147447. - DOI - PMC - PubMed
    1. Bilgili F, Balci HI, Karaytug K, Sariyilmaz K, Atalar AC, Bozdag E, Tuna M, Bilgic B, Gurler N. Can normal fracture healing be achieved when the implant is retained on the basis of infection? An experimental animal model. Clin Orthop Relat Res. 2015;473:3190–3196. doi: 10.1007/s11999-015-4331-9. - DOI - PMC - PubMed

Publication types