Diagnosing Fracture-Related Infections: Where Are We Now?

Abstract

Accurate diagnosis of fracture-related infection (FRI) is critical for preventing poor outcomes such as loss of function or amputation. Due to the multiple variables associated with FRI, however, accurate diagnosis is challenging and complicated by a lack of standardized diagnostic criteria. Limitations with the current gold standard for diagnosis, which is routine microbiology culture, further complicate the diagnostic and management process. Efforts to optimize the process rely on a foundation of data derived from prosthetic joint infections (PJI), but differences in PJI and FRI make it clear that unique approaches for these distinct infections are required. A more concerted effort focusing on FRI has dominated more recent investigations and publications leading to a consensus definition by the American Orthopedics (AO) Foundation and the European Bone and Joint Infection Society (EBJIS). This has the potential to better standardize the diagnostic process, which will not only improve patient care but also facilitate more robust and reproducible research related to the diagnosis and management of FRI. The purpose of this minireview is to explore the consensus definition, describe the foundation of data supporting current FRI diagnostic techniques, and identify pathways for optimization of clinical microbiology-based strategies and data.

Keywords: culture-negative infection; fracture-related infection; osteitis; osteomyelitis.

FIG 1

FRI diagnostic criteria. For confirmatory criteria, any single criterion is sufficient for a confirmatory diagnosis of FRI. For suggestive criteria, identification of any of these criteria should prompt further investigation, which may lead to identifying confirmatory criteria. FRI, fracture-related infection; PMNs, polymorphonuclear neutrophils; HPF, high-power field (×400 magnification); ESR, erythrocyte sedimentation rate; WBC, white blood cell; CRP, C-reactive protein. (Adapted from reference , which is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International licence [https://creativecommons.org/licenses/by-nc/4.0/].)