Understanding the basic principles for the treatment of FRI will help you develop a structured approach.

FRI treatment principles

Before treating a patient with FRI, consider the following elements:

• Early identification and intervention are key to optimizing patient outcomes. However, in non-septic patients there is time to get the patient at the right place for the best possible diagnostics and interventions. Refer complex cases to specialized centers for advanced multidisciplinary care.

• If you suspect FRI, do not start antibiotic treatment before a diagnostic workup (unless the patient is systemically ill).

• Inform patients about their condition, treatment plan, follow-up, and expected outcome.

• Prioritize the most cost-effective treatments.

• Patients should undergo host optimization (e.g., nutritional support, glycemic control) before and during definitive FRI management.

• Effective surgical debridement is the most important and probably also the most difficult step of surgical treatment. Remove dead tissue carefully to avoid creating large bone defects. Combine this procedure with diagnostic sampling taking deep cultures only.
  • Paprika sign: During excision, be alert for bleeding from small blood vessels in the cortex that occurs when drilling or sawing bone. This is called the ‘paprika sign’, and it indicates vital bone.

• Irrigation: Use plenty of saline; avoid additives.

• Start antibiotic treatment according to local protocols or previous cultures. If those are not available, treat for the most likely pathogens.

• After debridement and diagnostic sampling, perform:
  • Appropriate fracture stabilization
  • Adequate management of bone and/or soft tissue defects

Adjust targeted antimicrobial therapy based on culture results.

While the focus tends to be on the technical aspects of the treatment and specific antibiotic regimens, you must take patient factors into account when devising a treatment plan. You are treating a patient, not a disease. Shared decision making is recommended in any complex surgical condition with different treatment options that have specific risks and benefits.

Read more about surgical management in: “The surgical management of fracture-related infection. Surgical strategy selection and the need for early surgical intervention,” Marais et al. (2024).

Putting the actions into a flow chart makes the process more practical:

Emergency management

Patients with life-threatening sepsis must receive IV fluids and broad-spectrum antibiotics within two hours of presentation. In such cases, take blood cultures before antibiotic administration to guide targeted therapy. Urgent surgical intervention may be required in unstable or rapidly progressing cases. Consider amputation if sepsis is severe (‘life over limb’).

Timing of surgery

While it may be tempting to send a patient to the operation room straight away to prevent further infection, this might not be the preferred choice for the best outcomes, except for the life-threatening infections. Host optimization, soft tissue assessment and multidisciplinary consultation should be performed if the situation allows for it.

The flowchart below may help you decide when to perform surgery.

Host optimization and the multidisciplinary approach

The general health of the patient is both a predictor for the development of an FRI and a pillar of treatment. As one of the treatment principles, it is a form of tertiary prevention.

Improving the general health of a patient to improve treatment outcomes is called host optimization.

Effective host optimization is best done by a team of specialists:

• Trauma/orthopedic surgeon
• Plastic surgeon
• Microbiologist/infectious disease specialist
• Radiologist
• Nutritionist/endocrinologist
• Rehabilitation specialist
• Physiotherapist
• Consider: internal medicine specialist, geriatric specialist, anesthesiologist

Such a team is known as a multidisciplinary team (MDT). When therapy-focused decision making is performed by an MDT, patient outcomes improve significantly, showing fewer amputations, fewer revisions, and more use of local antibiotics. Furthermore, there was a trend in the reduction of recurrent infection and treatment failures.

Read more about MDT care in Rupp et al. (2023), “Multidisciplinary Treatment of Fracture-Related Infection Has a Positive Impact on Clinical Outcome—A Retrospective Case Control Study at a Tertiary Referral Center.”

Early FRI management vs late FRI management

Early FRI (<6 weeks) can often be managed at any facility that provides operative fracture care, especially when using internal fixation techniques. In early FRI, early intervention is improtant to ensure good outcomes.

In late/chronic FRI, host-optimization and a multidiciplinary approach should be priority.

Surgery is usually required to effectively diagnose and manage FRI. If surgery is not feasible, suppressive antibiotics may control symptoms but rarely eradicate the infection, this approach is not recommended. This decision must be documented, including the planned duration of therapy.

Key steps include:

• Diagnostic sampling: Obtain microbiological samples before starting antibiotics during surgery.
• Debridement: Remove all non-viable tissue and thoroughly irrigate the wound.
• Fracture stabilization:
  • Unstable FRI require external or internal fixation.
  • Stable prior fixation with satisfactory reduction may be retained in early FRI (DAIR)
  • In case of chronic/late FRI consider debridement antibiotics and implant exchache(DAIEX) or removal if the fracture is stable.
  • In resource limited setting, implants may be sterilized instead of exchanged.
  • Always consider exchange of infected intramedullary nails as debridement of a nail is challenging.
  • Inadequate prior fixation should be removed and replaced.
• Soft tissue management: Definitive good-quality soft tissue closure is required. If complex defects are present, involve plastic surgical expertise where available.

In late presentation, especially with prolonged presence of wounds (>6 weeks) the implant retention is less likely to be successful and if possible it should be exchanged for a new fixation is the fracture is still unstable.

Single versus multi-stage

If the debridement can be performed adequately leaving only healthy tissue and a direct sore tissue reconstruction is possible singe stage surgery is recommended. Multi-stage procedures are preferred if there are signs of systemic sepsis, or uncontrollable local infection with for example, a large accumulation of pus. If these factors are not present, make an orthoplastic collaborative decision: Quality of the remaining bone, soft tissues and host status all influence the choice of single or multi-stage strategies.

Follow-up and Outcomes

• Minimum 12-month follow-up is recommended.
• Monitor wound healing, fracture union, antibiotic side effects, and infection recurrence.
• Track outcomes: re-operation, non-union, recurrence, amputation, death.
• Hospitals should maintain a surgical site infection surveillance system.