Chinese Expert Consensus on Diagnosis and Treatment of Infection After Fracture Fixation (2019, English Version)
Core Overview：Published by Chinese Orthopaedic Association (COA) in Injury (2019 Nov;50(11):1952-1958), this consensus standardizes the classification, diagnosis, and treatment of infection after fracture fixation (IAFF, also known as fracture-related infection, FRI). It emphasizes early accurate diagnosis, radical debridement, personalized implant management, targeted antibiotics, and staged reconstruction to reduce recurrence and disability.
1. Basic Information
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Item |
Details |
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Full Title |
Chinese expert consensus on diagnosis and treatment of infection after fracture fixation |
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Issuing Body |
Chinese Orthopaedic Association (COA) |
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Publication Date |
August 6, 2019; Published in Injury (2019) |
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Corresponding Authors |
Yu Bin (Nanfang Hospital), Zhang Yingze (Third Hospital of Hebei Medical University), Tang Peifu (PLA General Hospital), Wu Xinbao (Beijing Jishuitan Hospital) |
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Core Scope |
Adult IAFF (early/delayed/late); diagnosis, debridement, implant handling, antibiotics, reconstruction, rehabilitation |
2. Classification of IAFF (By Onset Time)
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Type |
Time Window |
Key Features |
Common Pathogens |
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Early infection |
<2 weeks |
Acute inflammation (red/swelling/pain/purulent drainage), fever; high virulence |
S. aureus (MSSA), Gram-negative bacilli |
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Delayed infection |
2–10 weeks |
Subacute symptoms, sinus tract formation, impaired fracture healing |
Coagulase-negative staphylococci, P. acnes, Enterobacterales |
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Late infection |
>10 weeks |
Chronic osteomyelitis, recurrent sinus, implant loosening, bone destruction |
Low-virulence pathogens, biofilm-forming bacteria |
3. Diagnostic Criteria (Gold Standard: Histopathology + Microbiological Confirmation)
3.1 Definitive Diagnosis (Any 1 of the Following)
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Sinus/fistula directly communicating with bone or implant;
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Purulent drainage/pus found intraoperatively around implant/bone;
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At least 2 separate cultures from suspected infection sites yielding the same pathogen;
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Histopathology confirming infection (neutrophilic infiltration, microbial presence on special stain)PubMed.
3.2 Diagnostic Workup (Stepwise)
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Modality |
Key Indications & Findings |
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Clinical Assessment |
History (trauma/surgery/antibiotics), signs (local inflammation, sinus, pain, fever), risk factors (diabetes, immunocompromise, open fracture) |
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Laboratory Tests |
ESR, CRP (dynamic monitoring), WBC; blood cultures (before antibiotics) |
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Imaging |
- X-ray: Early (normal/soft-tissue swelling); Late (osteolysis, implant loosening, sequestrum)
- CT: Bone destruction, sequestrum, implant position
- MRI: Soft-tissue abscess, osteomyelitis, implant-related inflammation
- ¹⁸F-FDG PET/CT: For occult infection, biofilm, and multifocal disease
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Microbiology |
- Intraoperative specimens (deep tissue/bone/implant surface) > superficial swabs
- Culture (aerobic/anaerobic/fungal) + PCR (for fastidious/biofilm pathogens)
- Antibiotic susceptibility testing (AST)
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Histopathology |
Gold standard: Neutrophils ≥5/HPF, microbial invasion, bone necrosis |
4. Treatment Principles & Core Strategies
4.1 General Principles
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Radical debridement (remove necrotic bone/soft tissue, biofilm, foreign material) is the cornerstone;
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Personalized implant management (retain/remove/replace) based on infection stage, fracture stability, and healing status;
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Targeted antibiotics (systemic + local) guided by culture/AST;
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Staged reconstruction (soft-tissue coverage → bone reconstruction → functional rehabilitation);
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Multidisciplinary collaboration (orthopaedics, infectious diseases, microbiology, plastic surgery).
4.2 Implant Management (Critical Decision)
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Scenario |
Recommendation |
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Early infection, fracture stable, no implant loosening |
Retain implant; radical debridement + irrigation + local antibiotics + targeted systemic antibiotics |
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Delayed/late infection, implant loosening, unstable fracture, or uncontrolled infection |
Remove implant; convert to external fixation (Ilizarov/hybrid) or temporary cement spacer; re-implant after infection eradication |
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Fracture healed, late infection |
Remove implant; debridement + antibiotics; consider arthrodesis/reconstruction if needed |
4.3 Antibiotic Therapy (Systemic + Local)
4.3.1 Systemic Antibiotics
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Empiric therapy (before culture results): Cover Gram-positive (vancomycin/linezolid) + Gram-negative (piperacillin-tazobactam/cefepime) + anaerobic (metronidazole) pathogens; adjust for MRSA risk.
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Targeted therapy (after culture/AST): Narrow-spectrum, long-course (4–6 weeks for acute; 8–12 weeks for chronic osteomyelitis).
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Monitoring: CRP/ESR decline, clinical improvement, no recurrence.
4.3.2 Local Antibiotics
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Indications: Debridement cavity, biofilm, high-risk recurrence.
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Options: Antibiotic-loaded cement (vancomycin + gentamicin), calcium sulfate carriers, collagen sponges.
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Avoid: Local antibiotics alone without systemic therapy.
4.4 Debridement & Irrigation
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Radical debridement: Remove all necrotic bone (cortical/cancellous), devitalized soft tissue, implant biofilm, and foreign material.
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Irrigation: High-pressure pulsatile lavage with normal saline; avoid hydrogen peroxide/povidone-iodine (tissue toxicity).
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Re-debridement: For persistent infection, repeat debridement within 48–72 h.
4.5 Reconstruction (Staged)
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Soft-tissue coverage: NPWT (negative-pressure wound therapy) → local/ free flap (within 3–7 d after debridement) for large defects.
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Bone reconstruction: After infection eradication (CRP normal, no clinical signs):
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Autologous bone graft (iliac crest);
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Masquelet technique (induced membrane + bone graft);
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Ilizarov bone transport (for large bone defects/osteomyelitis).
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Implant re-implantation: After 6–12 weeks of infection control, confirm with imaging/CRP; use internal fixation (plate/screw/nail) or arthroplasty (for joint-involved fractures).
4.6 Rehabilitation
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Early: Pain control, wound care, passive range of motion (ROM), avoid weight-bearing.
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Intermediate: Active ROM, muscle strengthening, gradual weight-bearing (based on fracture healing).
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Late: Functional training, return to daily/sport activities; monitor for recurrence for ≥12 months.
5. Prevention & Follow-Up
5.1 Prevention
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Preoperative: Optimize comorbidities (diabetes, malnutrition), antibiotic prophylaxis (30–60 min before incision).
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Intraoperative: Aseptic technique, minimal soft-tissue dissection, proper implant selection, thorough irrigation.
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Postoperative: Wound care, early mobilization, monitor inflammatory markers, avoid prolonged catheterization.
5.2 Follow-Up
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Short-term (0–3 months): Weekly clinical/CRP/ESR; wound healing, infection control.
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Medium-term (3–12 months): Monthly imaging (X-ray/CT); fracture healing, no recurrence.
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Long-term (1–2 years): Quarterly assessment; functional outcome, late infection/nonunion.
6. Key Clinical Takeaways
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IAFF is a biofilm-related infection; debridement + implant management + targeted antibiotics are the triad of treatment.
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Histopathology + dual-site culture is the gold standard for diagnosis; avoid over-reliance on superficial swabs.
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Implant retention is feasible in early, stable infections; removal is mandatory for loosening/uncontrolled infection.
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Staged reconstruction (soft-tissue first, then bone) improves outcomes and reduces recurrence.
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Long-term follow-up (≥12 months) is critical to detect late recurrence.
7. Reference & Access
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Full Text: Injury. 2019 Nov;50(11):1952-1958. https://pubmed.ncbi.nlm.nih.gov/31445830/PubMed
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Chinese Version: Chinese Journal of Orthopaedic Trauma, 2018, 20(11): 929-936 (2018 edition, basis of the 2019 English consensus)
Clinical Quick Reference Card
✅ Screen: Post-fracture fixation pain/swelling/sinus + elevated CRP/ESR → suspect IAFF
✅ Diagnose: Deep tissue/bone culture (2 sites) + histopathology → confirm
✅ Treat: Radical debridement → implant retain/remove → targeted antibiotics (systemic + local) → staged reconstruction
✅ Prevent: Perioperative antibiotics + asepsis + comorbidity optimization
✅ Follow: CRP/ESR + imaging for ≥12 months