Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled
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TRAUMA SURGERY
Management of critical‑sized bone defects in the treatment of fracture‑related infection: a systematic review and pooled analysis H. Bezstarosti1 · W. J. Metsemakers2,5 · E. M. M. van Lieshout1 · L. W. Voskamp1 · K. Kortram1 · M. A. McNally3 · L. C. Marais4 · M. H. J. Verhofstad1 Received: 9 June 2020 / Accepted: 14 July 2020 © The Author(s) 2020
Abstract Purpose This systematic review determined the reported treatment strategies, their individual success rates, and other outcome parameters in the management of critical-sized bone defects in fracture-related infection (FRI) patients between 1990 and 2018. Methods A systematic literature search on treatment and outcome of critical-sized bone defects in FRI was performed. Treatment strategies identified were, autologous cancellous grafts, autologous cancellous grafts combined with local antibiotics, the induced membrane technique, vascularized grafts, Ilizarov bone transport, and bone transport combined with local antibiotics. Outcomes were bone healing and infection eradication after primary surgical protocol and recurrence of FRI and amputations at the end of study period. Results Fifty studies were included, describing 1530 patients, the tibia was affected in 82%. Mean age was 40 years (range 6–80), with predominantly male subjects (79%). Mean duration of infection was 17 months (range 1–624) and mean follow-up 51 months (range 6–126). After initial protocolized treatment, FRI was cured in 83% (95% CI 79–87) of all cases, increasing to 94% (95% CI 92–96) at the end of each individual study. Recurrence of infection was seen in 8% (95% CI 6–11) and amputation in 3% (95% CI 2–3). Final outcomes overlapped across treatment strategies. Conclusion Results should be interpreted with caution due to the retrospective and observational design of most studies, the lack of clear classification systems, incomplete data reports, potential underreporting of adverse outcomes, and heterogeneity in patient series. A consensus on classification, treatment protocols, and outcome is needed to improve reliability of future studies. Keywords Fracture-related infection · Bone transport · Induced membrane technique · Vascularized bone graft · Treatment
Introduction
* H. Bezstarosti [email protected] 1
Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
2
Department of Trauma Surgery, University Hospitals Leuven, Louvain, Belgium
3
Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
4
Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
5
Department of Development and Regeneration, KU Leuven, Louvain, Belgium
Segmental bone loss after trauma remains a challenging problem for orthopedic trauma surgeons. When a bone defect exists combined with fracture-related infection (FRI), the chances of successful bone consolidation and clearance of infection are reduced. A ‘critical-sized’
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