EMERGING INTRAOPERATIVE DIAGNOSTIC MODALITIES FOR FRACTURE-RELATED INFECTION: A SCOPING REVIEW

Aim Fracture-related infections (FRI) remains a significant challenge in orthopedic trauma care. Conventional culturing of deep intraoperative samples is the current diagnostic standard, but confirmation occurs postoperatively, delaying targeted treatment. A scoping review was conducted to evaluate the current evidence on intraoperative diagnostics for FRIs. Real-time intraoperative diagnostic techniques may offer earlier detection and improved surgical decision-making, but their clinical value remains uncertain and requires further investigation. Method: A scoping review was conducted using PubMed, Embase, Scopus, and Web of Science. A predefined search strategy incorporating fracture, infections, intraoperative methods, and diagnosis identified 4,075 results. After deduplication, 2,425 abstracts were screened. Twelve studies were initially selected, and following full-text screening and snowballing, ten articles were included, focusing on intraoperative diagnostic modalities for FRIs, particularly fluorescence imaging and frozen section analysis. Results: Frozen section analysis was investigated in three studies, demonstrating high sensitivity and specificity for detecting FRIs, particularly in cases of fracture non-union. One study highlighted its strong negative predictive value, allowing reliable exclusion of active infections during revision surgery, while another confirmed its utility in predicting the absence of infection during conversion to arthroplasty after acetabular fracture fixation. However, its accuracy in diagnosing indolent infections remains uncertain. Fluorescence imaging was examined in three clinical studies, showing promise for real-time visualization of necrotic bone and bacterial presence. Intraoperative fluorescence-assisted imaging proved useful for distinguishing viable from necrotic bone in chronic infections, potentially enhancing surgical precision. Additionally, molecular imaging and fluorescence-guided debridement improved tissue viability assessment and infection detection. A study combining preoperative PET with intraoperative fluorescence imaging demonstrated noninvasive bacterial visualization on osteosynthesis devices. Four additional basic science studies explored fluorescence imaging techniques, providing insights into bone perfusion assessment and molecular tracer applications for bacterial detection. These studies introduced fluorescence-guided models for quantifying periosteal and endosteal blood flow, emphasizing the importance of patient-specific arterial input correction for accurate intraoperative imaging. Conclusions: Intraoperative diagnostic modalities for FRI, including fluorescence imaging and frozen section analysis, show promise in improving real-time infection detection and guiding surgical decision-making. However, current data remains scarce and lacks robust clinical validation. Further high-quality research is necessary to assess the accuracy, feasibility, and clinical impact of these approaches.