Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group

Abstract

A judicious, well-planned bone and soft tissue debridement remains one of the cornerstones of state-of-the-art treatment of fracture-related infection (FRI). Meticulous surgical excision of all non-viable tissue can, however, lead to the creation of large soft tissue defects. The management of these defects is complex and numerous factors need to be considered when selecting the most appropriate approach. This narrative review summarizes the current evidence with respect to soft tissue management in patients diagnosed with FRI. Specifically we discuss the optimal timing for tissue closure following debridement in cases of FRI, the need for negative microbiological culture results from the surgical site as a prerequisite for definitive wound closure, the optimal type of flap in case of large soft tissue defects caused by FRI and the role of negative pressure wound therapy (NPWT) in FRI. Finally, recommendations are made with regard to soft tissue management in FRI that should be useful for clinicians in daily clinical practice.Level of evidence Level V.

Keywords: Fasciocutaneous flap; Fracture; Fracture-related infection; Infection; Muscle flap; Negative pressure wound therapy; Soft tissue closure; Soft tissue cover; Soft tissue defects, flap.

Fig. 1

Fracture-related infection (FRI), caused by Enterobacter cloacae, in a 48 year-old male following intramedullary nailing of the tibia. A The patient presented with a draining fistula four months after the initial placement of the intramedullary nail. B, C After debridement a two-stage exchange of the nail was performed. The soft tissue defect was definitively closed with a free muscle (i.e. gracilis) flap. D One year postoperatively the flap had healed well and the patient remained infection free

Fig. 2

A polymicrobial fracture-related infection (FRI), in a 45 year-old female following plate osteosynthesis of the tibia. A The patient presented with a draining fistula 2 weeks after the initial procedure. B, C After debridement and removal of all hardware (inadequate reduction and implant loosing) (first stage), a ring fixator was placed and the soft tissue defect was definitively closed with a transverse musculocutaneous gracilis (TMG) flap (second stage). D One year postoperatively the flap had healed well and the patient remained infection free

Fig. 3

A culture-negative fracture-related infection (FRI) of the tibia in a 15-year-old polytrauma patient. Among multiple injuries, she sustained a Gustilo-Anderson type IIIB open tibia and fibula fracture of the left lower limb. She was admitted to a tertiary referral hospital 3 weeks after temporary fixation of the fractures with an external fixator. She was taken to the operating room due to an increase in serum inflammatory markers combined with purulent drainage from the wound under broad-spectrum antibiotic therapy. A, B A clinical image of wound taken during surgical debridement and an anteroposterior radiograph of the left lower limb showing the primary external fixation. C, D The wound was debrided, the tibia acutely shortened with the placement of a stable circular tensioned wire external ring fixator and the wound closed. A proximal corticotomy was performed to lengthen the tibia. Follow-up was uneventful, and local and systemic signs of infection disappeared within 2 weeks after the final surgery. The culture results remained negative. E, F A coronal CT-scan and an anteroposterior standard radiograph show the lengthening process of the proximal tibia. G, H An anteroposterior radiograph and a clinical image of the lower limbs 2 years after the injury, illustrating satisfactory wound healing with no clinical signs of infection. Moreover, the standard radiographs illustrate consolidation of the fracture and the proximal distraction site (restoring length and axis)