SLR - January 2024 - Boyle
Title: Key aspects of soft tissue management in fracture‑related infection: recommendations from an international expert groupReference: Marais LC, Hungerer S, Eckardt H, Zalavras C, Obremskey WT, Ramsden A, McNally MA, Morgenstern M, Metsemakers WJ; FRI Consensus Group. Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg. 2023 Nov 3. doi: 10.1007/s00402-023-05073-9. Epub ahead of print. PMID: 37921993.
Level of Evidence: Level V
Scientific Literature Review
Reviewed By: Madeline Juliette Boyle, DPM
Residency Program: Emory University School of Medicine Podiatric Medicine and Surgery Residency – Decatur, GA
Podiatric Relevance: Fracture-related infections (FRIs) are a common complication. In this article, the authors describe bone and soft tissue debridement as the cornerstone treatment of FRIs. Emphasis is placed on the importance of planning and appropriate choice of debridement and closure methods for management of FRIs and overall patient care. The key recommendations made based off FRIs may be applied to other bone and soft tissue infections that many foot and ankle surgeons treat daily.
Methods: A level V narrative review summarizing current evidence describing management of FRIs with key recommendations made regarding closure timing, need for negative wound cultures, soft tissue flaps, and negative pressure wound therapy (NPWT). Authors note there is limited data on soft tissue management in FRIs; therefore, data from the open fracture literature related to the prevention of FRIs is also included for broader insights regarding the management of established FRIs.
Results: The authors’ first recommendation is a multidisciplinary team approach for rapid restoration of a local barrier. A delay of more than one week in soft tissue coverage following debridement may increase risk for recurrent infection and either a short interval staged approach or closure at time of procedure is valid if definitive soft-tissue reconstruction is achieved. It’s noted that negative tissue cultures are not a prerequisite for definitive soft-tissue closure. Next, the authors report that muscle, free, and pedicled flaps all have comparable results for reconstruction of soft tissue defects and recommend muscle flaps in early infections of the lower extremity due to the potential for faster progression of fracture unions. Lastly, the authors note that NPWT is misleading and should not be seen as wound “therapy”, but rather as a temporary wound dressing or treatment. NPTW should be seen as a bridge to final soft tissue coverage and kept to a minimum.
Conclusions: Management of FRIs can be complex and treatment involves several factors. The authors focus on several key points that they believe will promote better patient outcomes if applied. First, they emphasize that definitive soft tissue closure and bone stability should be at the forefront of treatment planning. The use of soft tissue flaps is discussed and focuses on individualized patient treatment depending on the size and location of the soft tissue and/or bony defect. Unsurprisingly, beginning broad spectrum antibiotics is suggested; however, the authors state that having negative wound cultures is not necessary for final soft tissue closure to proceed. Finally, the authors discuss the role of NPWT. Long-term use (greater than 1 week) of NPWT is strongly discouraged. They emphasize that NPWT should only be used as a temporary (less than 1 week) wound dressing when final closure cannot be completed. Overall, these recommendations are grounded in improved patient care and outcomes following FRIs and have validity in treatment of FRI’s as well as several other bony and soft tissue infections that foot and ankle surgeons will encounter daily as well.