Optimising fracture-related infection management:A narrative review of diagnostic precision, surgical timing,and antimicrobial stewardship
DOI:
https://doi.org/10.21142/mecp.2026.1.1.e011Keywords:
Fractures, Bone, Surgical Wound Infection, Osteomyelitis, Consensus, Anti-Bacterial AgentsAbstract
This narrative review synthesises contemporary fracture-related infection (FRI) management with an emphasis on reducing failure in diagnostic and treatment grey zones. We summarise consensus definitions that separate confirmatory from suggestive criteria and translate them into a practical diagnostic bundle linking clinical assessment, inflammatory markers, selective imaging, and disciplined microbiological and histological sampling. Imaging is framed as a problem-solving tool rather than a stand-alone rule-in test in equivocal cases. We outline a surgical decision matrix based on infection timing, fixation and fracture stability, host factors, and soft-tissue status, and we integrate local and systemic antimicrobial strategies with stewardship principles, including sampling before antibiotics when feasible and early de-escalation. Evidence quality is heterogeneous, and many recommendations derive from consensus and observational data; therefore, areas of uncertainty and priorities for prospective studies are highlighted.
Downloads
References
1. Foster AL, Warren J, Vallmuur K, Jaiprakash A, Crawford R, Tetsworth K, et al. A population-based epidemiological and health economic analysis of fracture-related infection. Bone Joint J. 2024;(1):77-85. doi: 10.1302/0301-620x.106b1.bjj-2023- 0279.r2.
2. Wang B, Xiao X, Zhang J, Han W, Hersi SA, Tang X. Epidemiology and microbiology of fracture-related infection: a multicenter study in Northeast China. J Orthop Surg Res. 2021;16(1):490. doi: 10.1186/s13018-021-02629-6.
3. Haidari S, Buijs MAS, Plate JDJ, Zomer JJ, IJpma FFA, Hietbrink F, et al. Costs of fracture-related infection: the impact on direct hospital costs and healthcare utilisation. Eur J Trauma Emerg Surg. 2024;50(4):1701-7. doi: 10.1007/ s00068-024-02497-9.
4. Bezstarosti H, Lieshout EMMV, Voskamp L, Kortram K, Obremskey WT, McNally M, et al. Insights into treatment and outcome of fracture-related infection: a systematic literature review. Arch Orthop Trauma Surg. 2018;139(1):61-72. doi: 10.1007/s00402-018-3048-0.
5. Vanvelk N, Lieshout EMMV, Onsea J, Sliepen J, Govaert GAM, IJpma FFA, et al. Diagnosis of fracture-related infection in patients without clinical confirmatory criteria: an international retrospective cohort study. J Bone Jt Infect. 2023;8(2):133-42. doi: 10.5194/jbji-8-133-2023.
6. Govaert GAM, Kuehl R, Atkins BL, Trampuž A, Morgenstern M, Obremskey WT, et al. Diagnosing fracture-related infection: current concepts and recommendations. J Orthop Trauma. 2019;34(1):8-17. doi: 10.1097/bot.0000000000001614.
7. Metsemakers W, Morgenstern M, Senneville É, Borens O, Govaert GAM, Onsea J, et al. General treatment principles for fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg. 2019;140(8):1013-27. doi: 10.1007/s00402-019-03287-4.
8. Foster AL, Moriarty TF, Trampuž A, Jaiprakash A, Burch MA, Crawford R, et al. Fracture-related infection: current methods for prevention and treatment. Expert Rev Anti Infect Ther. 2020;18(4):307-21. doi: 10.1080/14787210.2020.1729740.
9. Metsemakers W, Morgenstern M, McNally M, Moriarty TF, McFadyen I, Scarborough M, et al. Fracture-related infection: a consensus on definition from an international expert group. Injury. 2017;49(3):505-10. doi: 10.1016/j.injury.2017.08.040.
10. Bosch PG, den J van, Plate JDJ, IJpma FFA, Houwert RM, Huisman A, et al. Limited predictive value of serum inflammatory markers for diagnosing fracture-related infections: results of a large retrospective multicenter cohort study. J Bone Jt Infect. 2018;3(3):130-7. doi: 10.7150/jbji.26492.
11. Kieboom J van den, Bosch PG, Plate JDJ, IJpma FFA, Küehl R, McNally M, et al. Diagnostic accuracy of serum inflammatory markers in late fracture-related infection. Bone Joint J. 2018;100-B(12):1542-1550. doi: 10.1302/0301-620x.100b12.bjj2018-0586.r1.
12. Quinlan ND, Jennings JM. Joint aspiration for diagnosis of chronic periprosthetic joint infection: when, how, and what tests? Arthroplasty. 2023;5(1):43. doi: 10.1186/s42836-023- 00199-y.
13. Li C, Renz N, Trampuž A, Ojeda-Thies C. The value of conventional radiographs for diagnosing internal fixation-associated infection. BMC Musculoskelet Disord. 2021;22(1):411. doi: 10.1186/s12891-021-04170-3.
14. Sambri A, Spinnato P, Tedeschi S, Zamparini E, Fiore M, Zucchini R, et al. Bone and joint infections: the role of imaging in tailoring diagnosis to improve patients’ care. J Pers Med. 2021;11(12):1317. doi: 10.3390/jpm11121317.
15. Hofmann UK, Eleftherakis G, Migliorini F, Fink B, Mederake M. Diagnostic and prognostic relevance of plain radiographs for periprosthetic joint infections of the hip: a literature review. Eur J Med Res. 2024;29(1):314. doi: 10.1186/s40001-024- 01891-8.
16. Christersson A, Larsson S, Sörensen J. Presurgical localization of infected avascular bone segments in chronic complicated posttraumatic osteomyelitis in the lower extremity using dual-tracer PET/CT. EJNMMI Res. 2018;8(1):65. doi: 10.1186/ s13550-018-0426-0.
17. Yang M, Tan Q, Li T, Chen J, Hu W, Zhang Y, et al. FRID-PI: a machine learning model for diagnosing fracture-related infections based on 18F-FDG PET/CT and inflammatory markers. Front Med (Lausanne). 2025;12:1534988. doi: 10.3389/ fmed.2025.1534988.
18. Bosch PG, Glaudemans AWJM, Vries JPM de, Middelberg TR, Govaert GAM, IJpma FFA. Nuclear imaging for diagnosing fracture-related infection. Clin Transl Imaging. 2020;8(4):289- 98. doi: 10.1007/s40336-020-00374-0.
19. Sacher SE, Koff MF, Tan ET, Burge AJ, Potter HG. The role of advanced metal artifact reduction MRI in the diagnosis of periprosthetic joint infection. Skeletal Radiol. 2023;53(10):1969-78. doi: 10.1007/s00256-023-04483-5.
20. Díaz-Ledezma C, Espinosa-Mendoza R, Gallo J, Glaudemans AWJM, Gómez-García F, Goodman SB, et al. General Assembly, Diagnosis, Imaging: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty. 2018;34(2S):S215-S223. doi: 10.1016/j.arth.2018.09.073.
21. Glaudemans AWJM, Bosch PG, Slart RHJA, IJpma FFA, Govaert GAM. Diagnosing fracture-related infections: can we optimize our nuclear imaging techniques? Eur J Nucl Med Mol Imaging. 2019;46(8):1583-7. doi: 10.1007/s00259-019- 04378-5.
22. Govaert GAM, Bosch PG, IJpma FFA, Glauche J, Jutte PC, Lemans JVC, et al. High diagnostic accuracy of white blood cell scintigraphy for fracture related infections: results of a large retrospective single-center study. Injury. 2018;49(6):1085-90. doi: 10.1016/j.injury.2018.03.018.
23. Glaudemans AWJM, Jutte PC, Cataldo MA, Cassar-Pullicino VN, Gheysens O, Borens O, et al. Consensus document for the diagnosis of peripheral bone infection in adults: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging. 2019;46(4):957-90. doi: 10.1007/ s00259-019-4262-x.
24. Lemans JVC, Hobbelink MGG, IJpma FFA, Plate JDJ, Kieboom J van den, Bosch PG, et al. The diagnostic accuracy of 18F-FDG PET/CT in diagnosing fracture-related infections. Eur J Nucl Med Mol Imaging. 2018;46(4):999-1008. doi: 10.1007/ s00259-018-4218-6.
25. Moriarty TF, Muthukrishnan G, Daiss J, Xie C, Nishitani K, Morita Y, et al. Bone infection: a clinical priority for clinicians, scientists and educators. Eur Cell Mater. 2021;42:312-33. doi: 10.22203/ecm.v042a21.
26. Hannigan GD, Pulos N, Grice EA, Mehta S. Current concepts and ongoing research in the prevention and treatment of open fracture infections. Adv Wound Care (New Rochelle). 2014;4(1):59-74. doi: 10.1089/wound.2014.0531.
27. Hellebrekers P, Rentenaar RJ, McNally MM, Hietbrink F, Houwert M, Leenen LPH, et al. Getting it right first time: the importance of a structured tissue sampling protocol for diagnosing fracture-related infections. Injury. 2019;50(10):1649-55. doi: 10.1016/j.injury.2019.05.014.
28. Onsea J, Depypere M, Govaert GAM, Kuehl R, Vandendriessche T, Morgenstern M, et al. Accuracy of tissue and sonication fluid sampling for the diagnosis of fracturerelated infection: a systematic review and critical appraisal. J Bone Jt Infect. 2018;3(4):173-81. doi: 10.7150/jbji.27840.
29. Morgenstern M, Athanasou NA, Ferguson J, Metsemakers W, Atkins BL, McNally M. The value of quantitative histology in the diagnosis of fracture-related infection. Bone Joint J. 2018;(7):966-72. doi: 10.1302/0301-620x.100b7.bjj-2018-0052.r1.
30. Sigmund IK, McNally M, Luger M, Böhler C, Windhager R hard, Sulzbacher I. Diagnostic accuracy of neutrophil counts in histopathological tissue analysis in periprosthetic joint infection using the ICM, IDSA, and EBJIS criteria. Bone Joint Res. 2021;10(8):536-47. doi: 10.1302/2046-3758.108.bjr-2021- 0058.r1.
31. Ponraj DS, Falstie-Jensen T, Brüggemann H, Lange J. The value of sonication on orthopaedic implants in an everyday clinical setting, an exploratory study. BMC Musculoskelet Disord. 2023;24(1):691. doi: 10.1186/s12891-023-06796-x.
32. Rimoldi SG, Brioschi D, Curreli D, Salari F, Pagani C, Tamoni A, et al. Traditional cultures versus next generation sequencing for suspected orthopedic infection: experience gained from a reference centre. Antibiotics (Basel). 2023;12(11):1588. doi: 10.3390/antibiotics12111588.
33. Baertl S, Rupp M, Alt V. The DAIR-procedure in fracturerelated infection, when and how. Injury. 2024;55:111977. doi: 10.1016/j.injury.2024.111977.
34. Rimke C, Enz A, Bail HJ, Heppt P, Kladny B, Lewinski G von, et al. Evaluation of the standard procedure for the treatment of periprosthetic joint infections (PJI) in Germany, results of a survey within the EndoCert initiative. BMC Musculoskelet Disord. 2020;21(1):791. doi: 10.1186/s12891-020-03670-y.
35. Abouljoud MM, Backstein D, Battenberg AK, Dietz MJ, Erice A, Freiberg AA, et al. Hip and Knee Section, Treatment, Surgical Technique: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty. 2018;34(2S):S445-S451. doi: 10.1016/j.arth.2018.09.029.
36. Moore A, Wylde V, Whitehouse MR, Beswick AD, Walsh N, Jameson C, et al. Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection. Bone Jt Open. 2023;4(4):226-33. doi: 10.1302/2633- 1462.44.bjo-2022-0155.r1.
37. Liodakis E, Giannoudis VP, Harwood P, Giannoudis PV. Docking site interventions following bone transport using external fixation: a systematic review of the literature. Int Orthop. 2023;48(2):365-88. doi: 10.1007/s00264-023-06062-8.
38. Bezstarosti H, Metsemakers W, Lieshout E van, Kortram K, Voskamp L, McNally M, et al. Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis. Arch Orthop Trauma Surg. 2020;141(7):1215-30. doi: 10.1007/s00402-020-03525-0.
39. Depypere M, Kuehl R, Metsemakers W, Senneville É, McNally M, Obremskey WT, et al. Recommendations for systemic antimicrobial therapy in fracture-related infection: a consensus from an international expert group. J Orthop Trauma. 2019;34(1):30-41. doi: 10.1097/bot.0000000000001626.
40. Maale GE, Eager JJ, Mohammadi DK, Calderon FA. Elution profiles of synthetic CaSO4 hemihydrate beads loaded with vancomycin and tobramycin. Eur J Drug Metab Pharmacokinet. 2020;45(4):547-55. doi: 10.1007/s13318-020- 00622-8.
41. Vugt TAG van, Arts JJ, Geurts J. Antibiotic-loaded polymethylmethacrylate beads and spacers in treatment of orthopedic infections and the role of biofilm formation. Front Microbiol. 2019;10:1626. doi: 10.3389/fmicb.2019.01626.
42. Gorvetzian J, Kunkel R, Demas C. A single center retrospective evaluation of a surgical strategy to combat persistent soft tissue wounds utilizing absorbable antibiotic beads. Adv Wound Care (New Rochelle). 2018;8(2):49-57. doi:10.1089/ wound.2018.0795.
43. Masters EA, Trombetta RP, Bentley KL de M, Boyce BF, Gill AL, Gill SR, et al. Evolving concepts in bone infection: redefining “biofilm”, “acute vs. chronic osteomyelitis”, “the immune proteome” and “local antibiotic therapy”. Bone Res. 2019;7(1):20. doi:10.1038/s41413-019-0061-z.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Medical Education & Clinical Practice

This work is licensed under a Creative Commons Attribution 4.0 International License.


