Fracture-Related Infection: From Diagnosis to Eradication and Fracture Union A Contemporary Narrative Review and Practical Treatment Algorithm

Abstract

Fracture-related infection (FRI) remains one of the most demanding complications in orthopaedic trauma because successful treatment requires simultaneous control of infection, preservation or restoration of mechanical stability, fracture union, and recovery of a durable soft-tissue envelope. The international FRI consensus definition has transformed the field by separating confirmatory from suggestive diagnostic criteria and by discouraging the extrapolation of prosthetic joint infection algorithms to the fracture population. Nevertheless, substantial uncertainty persists regarding the optimal use of debridement, antibiotics and implant retention (DAIR), the timing of implant exchange, the role of local antimicrobial therapy, and the duration and composition of systemic treatment. This narrative review integrates current consensus recommendations with recent evidence on diagnostic biomarkers, microbiology, histopathology, biofilm-active therapy and surgical outcomes. A practical treatment algorithm is proposed. The central principle is that elapsed time alone should not determine implant retention. Instead, treatment should be individualized according to fracture healing, fixation stability and reduction, quality of debridement, soft-tissue condition, host status, presumed biofilm maturity, implant type, pathogen profile and previous treatment. When the fracture has healed, implant removal with radical debridement is generally the most direct strategy. In an unhealed fracture, DAIR may be appropriate when stable fixation, acceptable reduction, viable soft tissues and adequate source control can be achieved; otherwise, implant exchange is favored. Local antimicrobial delivery is an adjunct to, not a substitute for, meticulous surgery. Multidisciplinary care and standardized sampling remain essential. The objective is not simply to sterilize an implant but to create the biological and mechanical conditions in which infection control and fracture union can coexist.