Abstract
Aim
The aim of this systematic review was to determine 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.
Method
We performed a systematic literature search on treatment and outcome of critical-sized bone defects in FRI. Treatment strategies identified were, autologous cancellous grafts, autologous cancellous grafts combined with local antibiotics, the induced membrane technique, vascularized grafts, bone transport, and bone transport combined with local antibiotics. Studies describing bone defects of 1 cm or greater were included. 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 1,530 patients, of which the tibia was affected in 82%. The 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 lasted 51 months (range 6–126). Four studies (8%) described treatment using vascularized grafts, 18 (36%) cancellous grafts, 8 (16%) the induced membrane technique, and 20 (40%) bone transport. A total of 1063 grafts were used of which 30% were vascularized and 60% were cancellous bone. 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).
Conclusions
This is the first extensive review of bone defect treatment protocols in chronic/late-onset FRI. Overall published work showed a high success rate of 94% and low amputation rate of only 3%. However, data did not allow a reliable comparison across treatments. The results should thus 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 in order to improve reliability of future studies.
