This AO Foundation/EBJIS/OTA consensus review summarizes diagnostic evidence across all domains for fracture-related infection (FRI). It proposes updates to the 2018 FRI consensus definition, formally adding nuclear imaging and bimodal histopathology as additional criteria. The goal is a standardized, multidisciplinary diagnostic pathway for a condition that had no uniform definition until recently.
A fistula, purulent drainage, or pus at surgery ends the diagnostic workup — FRI is confirmed, and the team should move directly to treatment planning.
When the picture is less clear (elevated CRP, nonunion, late wound drainage without overt pus), use the suggestive criteria as a trigger for further investigation: order nuclear imaging (WBC scintigraphy + SPECT/CT preferred; avoid FDG-PET within 1 month of surgery) and plan operative tissue sampling.
At surgery, the sampling protocol is fixed: ≥5 deep specimens from the implant-bone interface, no-touch technique, no swabs, enrichment broth cultures run for 10–14 days. For chronic nonunion, send tissue for quantitative histopathology. Absent PMNs effectively rules out infection (98% specificity), while >5 PMNs/HPF confirms it (100% specificity).
Before this consensus framework, FRI had no universally accepted definition, and treatment decisions were largely extrapolated from PJI algorithms. This paper formalizes what is actually different about FRI and gives you a defensible, evidence-grounded diagnostic pathway.
This AO Foundation/EBJIS/OTA consensus review summarizes diagnostic evidence across all domains for fracture-related infection (FRI). It proposes updates to the 2018 FRI consensus definition, formally adding nuclear imaging and bimodal histopathology as additional criteria. The goal is a standardized, multidisciplinary diagnostic pathway for a condition that had no uniform definition until recently.
A fistula, purulent drainage, or pus at surgery ends the diagnostic workup — FRI is confirmed, and the team should move directly to treatment planning.
When the picture is less clear (elevated CRP, nonunion, late wound drainage without overt pus), use the suggestive criteria as a trigger for further investigation: order nuclear imaging (WBC scintigraphy + SPECT/CT preferred; avoid FDG-PET within 1 month of surgery) and plan operative tissue sampling.
At surgery, the sampling protocol is fixed: ≥5 deep specimens from the implant-bone interface, no-touch technique, no swabs, enrichment broth cultures run for 10–14 days. For chronic nonunion, send tissue for quantitative histopathology. Absent PMNs effectively rules out infection (98% specificity), while >5 PMNs/HPF confirms it (100% specificity).
Before this consensus framework, FRI had no universally accepted definition, and treatment decisions were largely extrapolated from PJI algorithms. This paper formalizes what is actually different about FRI and gives you a defensible, evidence-grounded diagnostic pathway.