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Review Article
- Fracture-related infections: a comprehensive review of diagnosis and prevention
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HoeJeong Chung, MD
, Hoon-Sang Sohn, MD -
Journal of Musculoskeletal Trauma 2025;38(2):86-95.
DOI: https://doi.org/10.12671/jmt.2025.00164
Published online: April 25, 2025
Department of Orthopedic Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Correspondence to: Hoon-Sang Sohn, MD Department of Orthopedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea Tel: +82-033-741-0607 Email: traumasohn@yonsei.ac.kr
• Received: March 27, 2025 • Revised: April 5, 2025 • Accepted: April 7, 2025
© 2025 The Korean Fracture Society
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract
- Fracture-related infections are challenging complications in orthopedic trauma that often require prolonged treatment and impose a significant healthcare burden. Accurate diagnosis and effective prevention strategies are essential for minimizing their occurrence. A recent international consensus has established standardized diagnostic criteria based on clinical, microbiological, radiological, and histopathological findings. Prevention is the top priority and involves a thorough preoperative risk assessment, along with glycemic control, nutritional optimization, and management of comorbidities, as well as intraoperative and postoperative measures such as appropriate antibiotic prophylaxis, surgical site antisepsis, and meticulous wound care. A multidisciplinary approach involving orthopedic surgeons, infectious disease specialists, and microbiologists is crucial for successfully reducing the burden of fracture-related infections.
Introduction
In orthopedic surgery, infections pose a major challenge, requiring prolonged treatment and considerable patience from both doctors and patients. Beyond merely extending the treatment duration, infections contribute to increased medical costs and, more importantly, can lead to long-term complications and functional impairments.
Orthopedic trauma varies widely in severity, ranging from isolated fractures to complex injuries involving soft tissue damage and multiple organ trauma. In severe cases, such injuries may even become life-threatening. Among these, fracture-related infection (FRI) is a particularly serious complication, significantly impacting patient outcomes.
FRI occurs with exceptionally high frequency in open fractures, with reported infection rates exceeding 20% depending on the severity of the injury [1]. However, infection risk is not solely determined by the nature of the fracture. A multitude of factors contributes to FRI, including patient-related factors (e.g., diabetes, smoking history), fracture-related factors (e.g., fracture classification, anatomical location), and surgical factors (e.g., antiseptic preparation, surgical technique). Given its complex multifactorial nature, preventing and managing FRI remains a significant clinical challenge.
Historically, terms such as osteomyelitis and osteitis were used to describe bone infections, but a standardized definition specifically for FRIs had not been clearly established. This lack of consistency hindered both clinical diagnosis and research efforts. To address this issue, an international expert group, supported by the AO Foundation, Orthopaedic Trauma Association, and other organizations, proposed a consensus definition of FRI in 2018 [2]. This standardization has since played a critical role in enhancing research quality and improving clinical management strategies.
This review comprehensively summarizes recent advancements in diagnostic criteria and preventive strategies (preoperative, perioperative, and postoperative) to effectively reduce the incidence of FRI in orthopedic trauma patients.
Definition of FRI
The first internationally accepted definition and diagnostic criteria for FRI were established in 2018 [2]. This was later updated through a second consensus meeting, which included the Orthopaedic Trauma Association and other expert groups [3]. This review aims to summarize the definition and diagnostic process based on these consensus statements. FRI is classified into two diagnostic categories: confirmatory criteria and suggestive criteria, as outlined in Table 1.
Based on these two diagnostic criteria categories, FRI can be definitively diagnosed if at least one confirmatory criterion is met, prompting the initiation of treatment. However, if no confirmatory criteria are present but two or more suggestive criteria are met, further investigation is required to confirm the diagnosis. A single suggestive criterion alone is insufficient to diagnose FRI. In cases where only suggestive criteria (≥2) are present, deep tissue cultures and histopathological examination serve as the gold standard for confirming FRI.
Prevention Strategies of FRI
Preoperative prevention factors can be categorized into intrinsic factors and patient-related factors. Given the nature of fracture surgery, which is often unplanned rather than elective, implementing comprehensive preoperative prevention strategies can be challenging. However, the urgency of surgery should not be compromised by delaying necessary procedures solely for infection prevention.
Risk stratification for infection
Risk stratification and the establishment of appropriate preventive strategies are crucial in reducing FRI incidence. In particular, immunocompromised patients, those with chronic diseases, and obese individuals are at a significantly higher risk of developing FRI, necessitating meticulous management. Patients with compromised immune function are more susceptible to infections and therefore require comprehensive preventive measures. For instance, in diabetic patients, hyperglycemia impairs immune function and increases infection susceptibility, making strict glycemic control essential. Additionally, individuals with acquired immune deficiency syndrome, cancer, or those undergoing long-term immunosuppressive or steroid therapy have weakened immune defenses. For these patients, dose reduction of immunosuppressants and extended prophylactic antibiotic use should be considered.
Patients with chronic diseases are also classified as a high-risk group for infections. In patients with chronic kidney disease, prolonged systemic inflammation leads to increased uremic toxin levels, resulting in immune suppression. Furthermore, reduced angiogenesis and impaired soft tissue regeneration delay wound healing, thereby increasing the likelihood of infection. To mitigate this risk, nephrotoxic antibiotics should be avoided, and hypoxia should be actively prevented [4]. Similarly, patients with chronic liver disease are prone to infection due to hypoalbuminemia, which compromises immune function and delays wound healing. The associated edema and increased exudate further elevate infection risk. To address these issues, it is necessary to correct hypoalbuminemia and closely monitor platelet levels [5]. Obese patients (body mass index ≥30 kg/m2) are also at an increased risk of infection. Reduced soft tissue perfusion, along with a higher likelihood of wound dehiscence, makes surgical site infections (SSIs) more prevalent in this population. Additionally, obesity is associated with an increased risk of hypothermia and prolonged surgical duration, both of which contribute to greater blood loss and heightened infection risk. Thus, maintaining intraoperative normothermia and ensuring meticulous wound closure and care are essential. The use of negative pressure wound therapy (NPWT) should also be considered as a preventive strategy for wound management in obese patients [5].
Identifying high-risk patients early and implementing tailored preventive strategies play a vital role in reducing FRI incidence. A thorough evaluation of a patient’s underlying conditions and physiological status is necessary to determine the most effective management approach for each individual.
Glycemic control
Perioperative glycemic control plays a crucial role in reducing the risk of infection and optimizing surgical outcomes. Hyperglycemia impairs the innate immune system, promotes protein glycosylation, and delays wound healing [6]. Additionally, diabetic patients often experience a sharp rise in blood glucose levels postoperatively, making glycemic control more challenging [7]. Thus, maintaining optimal blood glucose levels is essential regardless of a patient’s diabetic status [8].
Several organizations have established guidelines for target blood glucose levels, with recommendations varying based on the degree of tight control. The Centers for Disease Control and Prevention (CDC, 2017) and the World Health Organization (WHO, 2016) provide different targets, as summarized in Table 2 [9,10]. For certain procedures, particularly cardiac surgery, tight glycemic control is emphasized during the immediate postoperative period. Although there is no universal consensus on how long strict glycemic control should be maintained, some cardiac surgery guidelines recommend keeping blood glucose levels within a controlled range for the first 24 hours after anesthesia cessation or until 6:00 AM on postoperative day 2 [11,12]. Given that some guidelines categorize orthopedic and cardiac surgery within the same risk group, these recommendations may serve as a useful reference for perioperative glucose management in orthopedic procedures.
Nutritional optimization
Malnutrition not only impairs collagen synthesis and granulation tissue formation, hindering tissue healing, but also increases the risk of SSIs. In particular, hypoalbuminemia promotes macrophage apoptosis, suppresses their activation, and increases the exudation of interstitial fluid at the surgical site, leading to edema. These mechanisms alter the immune system, ultimately contributing to a higher risk of infection [13].
However, there is a lack of clear guidelines or strong evidence regarding the effectiveness of nutritional support. According to WHO guidelines, oral or enteral nutritional support may be considered for underweight patients undergoing major surgery; however, this is classified as a conditional recommendation with very low-quality of evidence [9].
Steroid and immunosuppressant management
Steroids and immunosuppressants can impair the wound healing process by inhibiting the early phase of the inflammatory response [14]. Due to this mechanism, patients using these medications are at an increased risk of SSIs. However, there is ongoing debate regarding whether discontinuing these medications preoperatively and postoperatively is truly beneficial for infection prevention. Some studies suggest that preoperative discontinuation of immunosuppressants may have a positive effect on reducing infection risk [15,16], whereas others argue that discontinuation not only fails to prevent infections but also poses a risk of exacerbating underlying conditions (flare-up), potentially worsening the patient's overall health status [17,18]. Reflecting on these conflicting findings, the WHO does not consider preoperative discontinuation of immunosuppressive medications to be essential and instead recommends individualized decision-making based on the patient’s condition [9].
Management of preoperative concomitant infections
According to CDC guidelines, the presence of an infection should be identified and treated preoperatively, even if it is unrelated to the surgical site. This recommendation is classified as category IA (strongly recommended) [8]. However, these guidelines primarily apply to elective surgeries, and in fracture surgery, where emergency procedures are often unavoidable, preoperative treatment of concomitant infections can be challenging.
Despite these challenges, efforts should be made to identify preexisting infections before surgery whenever possible. Additionally, given the increased risk of postoperative infections in patients with preexisting infections, it is crucial to anticipate potential complications and implement proactive infection management strategies following fracture surgery.
Staphylococcus aureus decolonization
Staphylococcus aureus is one of the most common pathogens responsible for FRIs, with up to 30% of the general population carrying asymptomatic nasal colonization [19]. During surgery, these colonized bacteria can be transferred from the nasal cavity to the skin surface or other areas, increasing the risk of SSIs.
Both methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) can cause infections, but MRSA poses a greater challenge due to its limited treatment options. Patients with MRSA infections face fewer antibiotic choices, more difficult treatment, prolonged hospital stays, higher rates of complications, and increased mortality compared to those with MSSA infections [20]. Notably, Asia, particularly South Korea, has a higher prevalence of MRSA compared to other regions, necessitating more proactive measures to manage S. aureus colonization [21].
Due to these concerns, the WHO strongly recommends preoperative screening and decolonization of S. aureus in orthopedic surgeries [9]. Although standardized guidelines for decolonization are lacking, the application of 2% mupirocin to the nasal cavity before and after surgery is widely recognized as an effective approach [22,23].
Prophylactic antibiotics
Closed fractures
It is well-established that prophylactic antibiotics significantly reduces the risk of SSIs. The key principle is that appropriate antibiotics should be administered at the proper time. For closed fractures, prophylactic antibiotics are typically recommended only if surgical intervention is required, and a single dose administered within 1 hour before skin incision is considered sufficient [24].
An antibiotic that provides good coverage against gram-positive organisms and effectively penetrates the surgical site is generally recommended, and first-generation cephalosporins are commonly used for this purpose. However, circumstances may require repeated administration of prophylactic antibiotics, such as when the surgical duration exceeds twice the antibiotic's half-life, when significant blood loss occurs, or in complex osteosynthesis or joint arthroplasty procedures. In these situations, repeated antibiotic dosing is known to be more effective in preventing infections than a single-dose regimen [24,25].
Open fractures
For open fractures, the type and duration of prophylactic antibiotic administration vary according to the severity of the injury. Although it is common practice to base antibiotic strategies on the Gustilo-Anderson classification, controversies remain regarding the effectiveness of such an approach, and a universally accepted guideline has yet to be established. Intravenous prophylactic antibiotics should be administered as early as possible after an open fracture occurs; however, no clear guidelines currently exist regarding the optimal duration of therapy.
Clinically, it is common practice to add antibiotics effective against gram-negative organisms, such as aminoglycosides, to a first-generation cephalosporin in open fractures, though the effectiveness of this combination is still debated [2,26]. Regarding the duration of antibiotic administration, 24 to 48 hours is recommended for Gustilo-Anderson type I and II fractures, and no more than 72 hours is recommended for type III fractures [27,28]. However, in cases where the soft tissue has not been adequately reconstructed, the optimal duration of antibiotic administration remains controversial.
For severe open fractures accompanied by extensive soft-tissue injury—particularly Gustilo-Anderson type IIIC fractures involving vascular injuries—intravenous prophylactic antibiotics alone may not achieve sufficient local antibiotic concentration at the surgical site. In these scenarios, antibiotics such as gentamicin, tobramycin, or vancomycin have traditionally been mixed with bone cement and applied locally as beads or spacers. Several studies have reported that local administration of prophylactic antibiotics can be effective in preventing infection [29,30]. Despite the disadvantage that these antibiotic-loaded materials must be removed at the time of definitive fracture fixation following initial debridement, local antibiotic application, in conjunction with systemic prophylactic antibiotics, is now widely used in managing open fractures with contaminated wounds.
Surgical site preparation
Hair removal
Preoperative hair removal is generally discouraged, as it can increase the risk of SSI due to microscopic skin injuries. However, if hair removal is necessary because it interferes with the surgical procedure, the WHO recommends performing it outside the operating room and using clippers rather than razors [9,31].
Preoperative washing
Preoperative washing can reduce the bacterial load on the skin; however, it is often difficult to perform in patients with fractures. Therefore, it may be applied site-specifically when feasible. Given that there is no clear evidence showing the superiority of antimicrobial soap over regular soap, it is recommended to use whichever is available and practical [32].
Skin antisepsis
Skin antisepsis is widely recognized as crucial in preventing SSIs by reducing the microbial load at the surgical incision site. Commonly used antiseptics include povidone-iodine, alcohol, and chlorhexidine gluconate. It is known that chlorhexidine-alcohol is superior to povidone-iodine for clean-contaminated surgeries, and thus the WHO recommends chlorhexidine-alcohol use [9]. Of note, an in-vitro study has reported concerns regarding soft-tissue toxicity associated with povidone-iodine, suggesting caution against its use in open fractures [33].
Operative environment
Operating room ventilation systems
Operating room ventilation systems are critical in minimizing infections by reducing airborne microbial concentrations. It is essential to maintain a consistent temperature and humidity within operating rooms using heating, ventilation, and air conditioning systems. Ideally, the recommended operating room temperature for infection prevention is between 20 °C and 24 °C, with a relative humidity of 20%–60% [34].
To prevent contamination air entry, operating rooms should maintain positive pressure relative to adjacent areas [35]. This practice blocks external air inflow, thus protecting sterile zones. Laminar airflow systems are widely used for this purpose, as they direct airflow in a uniform direction, effectively minimizing the transfer of contaminated air to the surgical field. In particular, laminar airflow systems equipped with high-efficiency particulate air filters, which can remove 99.97% of airborne particles, are considered suitable for orthopedic surgeries that demand a strictly sterile environment [36].
Furthermore, minimizing the frequency of opening operating room doors is crucial for maintaining air quality. Frequent opening of doors decreases room pressure and increases the risk of contamination from external sources. Therefore, it is recommended that all necessary surgical instruments and equipment be prepared prior to surgery to reduce the frequency of door openings during the procedure [37,38].
Intraoperative behavior guidelines
There are specific intraoperative behavioral guidelines that surgical teams must follow to reduce the risk of infection, playing a critical role in preventing SSIs. The key guidelines are as follows [39].
First, surgical instruments should be opened immediately before use, and unnecessary handling should be minimized. To reduce the possibility of contamination and maintain sterility, all procedures within the operating room must adhere strictly to infection control standards.
Second, the number of personnel within the operating room should be kept to a minimum, restricting unnecessary access. Increased numbers of people and unnecessary movements can elevate airborne contaminants, thus increasing infection risk.
Third, unnecessary conversation and movements during surgery should be minimized. Studies indicate that unnecessary talking during surgery may disperse bacteria through masks into the surrounding air, while unnecessary movements create turbulent airflow, potentially disrupting the sterile field.
Fourth, surgical caps and masks must be worn correctly and replaced after each surgical procedure. Appropriate protective equipment should ensure no exposure of hair or nose, and new surgical attire and masks should be worn for each operation.
Strict adherence to these behavioral guidelines is considered essential for effective prevention of SSIs, significantly lowering infection risk during surgery.
Surgical techniques
General considerations
Fracture surgery inevitably involves soft-tissue injury; therefore, employing appropriate surgical techniques is crucial for preventing infections. There has been an ongoing debate regarding whether electrocautery or scalpel incision is more effective in minimizing SSIs. A recently published systematic review and meta-analysis reported that electrocautery incision significantly reduces bleeding, incision time, and postoperative pain compared to scalpel use, while showing no significant differences in infection rates, hospital stay duration, or cosmetic outcomes. Based on these findings, routine use of electrocautery for surgical incisions has been recommended [40,41].
Additionally, minimizing intraoperative blood loss is another essential factor in infection prevention, since blood transfusions may impair macrophage function, thereby increasing infection risk. Therefore, meticulous hemostasis during surgery is essential. Moreover, prolonged surgical duration increases the exposure of the surgical site to the external environment and elevates surgeon fatigue, both of which can lead to higher infection risk and technical errors. Thus, minimizing unnecessary intraoperative manipulations and thorough preoperative preparation to avoid procedural delays are crucial steps in reducing infection risk [42].
Debridement
Debridement is essential for preventing infection in open fractures. Traditionally, performing debridement within 6 hours following the fracture, referred to as the 'golden time,' has been emphasized as standard practice. However, recent studies have reported that the timing of debridement does not significantly affect infection rates [43,44]. Therefore, it is currently recommended that surgical debridement be performed as soon as the patient's condition is stabilized and proper surgical preparation has been completed. Regardless of timing, meticulous and thorough debridement remains critical.
The key principles of surgical debridement include [45]:
• Thorough removal of devitalized and contaminated tissues.
• Extension of excision until healthy tissue with confirmed adequate bleeding is exposed.
• Evaluating muscle viability based on indicators such as bleeding, color, and contractility.
• Removal of free bone fragments; however, articular bone fragments may be preserved if restoration of joint function is achievable.
In open fractures with severe contamination or significant soft-tissue injury, repeated debridement procedures may be required. In such cases, it is recommended that repeat debridement be performed 24 to 48 hours after the initial procedure and repeated as necessary until the wound is sufficiently clean to allow definitive wound closure or soft-tissue reconstruction [46].
Irrigation
Irrigation is an essential procedure in reducing infection risk by removing foreign materials and bacteria from the wound. However, controversy still remains regarding the optimal irrigation solutions and methods. While both the WHO and CDC guidelines suggest iodine-based solutions as being effective for preventing postoperative infections, these recommendations primarily originate from studies involving spinal and abdominal surgery, and thus their application in orthopedic surgery requires caution [9,10].
According to the FLOW (fluid lavage of open wounds) study published in 2015, low-pressure irrigation with normal saline produced the most effective outcomes [47]. Moreover, a 2021 meta-analysis suggested that pulsed lavage could reduce infection risk [48]. Nevertheless, excessive irrigation pressure may cause soft-tissue damage and facilitate deeper bacterial penetration into tissues; therefore, careful consideration of irrigation techniques is necessary.
Wound management
Wound management in open fractures is essential to optimize infection prevention and soft-tissue recovery; however, there is still ongoing debate regarding the optimal timing and method of wound closure. Some studies have raised concerns that primary wound closure may create an anaerobic environment, potentially increasing the risk of infectious complications such as gas gangrene. In contrast, other studies suggest immediate wound closure might prevent secondary infections and result in better clinical outcomes [49].
Primary wound closure can be considered if the soft-tissue injury is not extensive, severe contamination (e.g., oil, feces, etc.) is absent, and thorough initial debridement has been performed. Conversely, in cases with severe contamination, delayed closure after a second-look debridement within 24–48 hours is typically recommended. If wound closure is delayed, NPWT is recommended to lower infection risk [50].
When extensive wounds cannot be immediately closed, rapid soft-tissue reconstruction should be performed, ideally within 72 hours, to minimize the risk of secondary infections and ensure effective systemic antibiotic delivery. In all cases, definitive wound management should ideally be completed within 7 days [51].
Currently, evidence regarding differences in infection risk according to wound closure methods (e.g., nylon suture vs. skin staplers), wound disinfection techniques, and optimal timing for suture removal remains inconclusive [52,53]. Therefore, strict adherence to aseptic technique and thorough hand disinfection during wound care is considered more important for infection prevention than the specific closure method employed.
Recent studies have suggested prophylactic NPWT may be more effective in preventing infections compared to conventional wound care techniques [54,55]. The WHO also recommends considering NPWT in high-risk patients presenting factors such as severe soft-tissue injury, compromised blood flow, hematoma formation, and dead space [9]. Given that open fractures commonly involve these risk factors, NPWT may be particularly beneficial in such cases.
Conclusions
FRI is challenging to treat, and treatment failure can lead to severe complications and functional loss, making prevention the top priority. To achieve this, healthcare professionals must implement comprehensive infection prevention strategies and maintain continuous monitoring and management throughout the entire treatment process, including the emergency department, operating room, and inpatient wards.
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Author contributions
Conceptualization: HC, HSS. Formal analysis: HSS. Supervision: HSS. Writing-original draft: HC. Writing-review & editing: HSS. All authors read and approved the final manuscript.
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Conflict of interests
None.
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Funding
None.
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Data availability
Not applicable.
Article Information
Table 1.
Diagnostic criteria for FRIs
Table 2.
Perioperative glycemic control recommendations
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XML DownloadFracture-related infections: a comprehensive review of diagnosis and prevention
Fracture-related infections: a comprehensive review of diagnosis and prevention
| Criteria | Description | |
|---|---|---|
| Confirmatory | Fistula, sinus, or wound breakdown | Direct communication with the bone or implant |
| Purulent drainage from the wound or presence of pus | Visible pus or drainage indication of infection | |
| The same pathogen identified in at least 2 cultures | Microbiological confirmation through multiple samples | |
| Presence of microorganisms in deep tissue (histopathological confirmation) | Microscopic evidence using specific bacterial or fungal staining techniques | |
| Suggestive | Clinical signs | Any one of: pain, redness, swelling, increased local temperature, fever (≥38.3 °C) |
| Radiological signs | Bone lysis, implant loosening, sequestration, non-union, periosteal bone formation | |
| Pathogen in a single deep tissue/implant culture | Single positive deep tissue culture | |
| Elevated inflammatory markers | Elevated ESR, WBC, CRP | |
| Persistent wound drainage | Persistent, increasing, or new-onset wound drainage postoperatively | |
| New-onset joint effusion in fracture patients | FRIs may present as adjacent septic arthritis | |
| Nuclear imaging findings (FDG-PET/CT, WBC scintigraphy+SPECT/CT) | Abnormal uptake in PET/CT or SPECT/CT suggesting infection | |
| Guideline | Recommended blood glucose target (mg/dL) | Additional considerations |
|---|---|---|
| Centers for Disease Control and Prevention (2017) | <200 | General blood glucose control recommendation |
| World Health Organization (2016) | <150 | Tight glucose control recommended, but levels <110 mg/dL should be avoided due to hypoglycemia risk |
| Cardiac Surgery Guideline | <180 | Recommended for 24 hr on postoperative day 2 at 6:00 AM |
Table 1. Diagnostic criteria for FRIs
FRI, fracture-related infections; ESR, erythrocyte sedimentation rate; WBC, white blood cell; CRP, C-reactive protein; FDG, fluorodeoxyglucose; PET, positron emission tomography; CT, computed tomography; SPECT, single-photon emission computed tomography.
Table 2. Perioperative glycemic control recommendations
