Tissue cultures are the gold standard for FRI diagnosis. They are essential to guide targeted postoperative antimicrobial therapy, which is key for success. The rst sample collection and debridement surgery is the best opportunity to identify and characterize the causative pathogen, so adequate sample collection is essential.

oftentimes, implant removal would complicate fracture management, particularly in complex periarticular fractures. Thus, these fractures are often best managed with implant retention, equiv­alent to a DAIR (debridement, antibiotic and implant retention) strategy in PJI. A systematic review found high success rates in early and delayed infections (less than 10 weeks after implantation), with remission of infection in over 80% of patients, but poorer outcomes beyond that period (67% success rate) [10]. Fracture union can be achieved as long as the osteosynthesis con­struct remains stable, and suppression until bony union is a valid alternative, allowing for a less complex implant removal once the fracture has healed in case of persistent signs of infection vs. revision of internal xation. Rightmire et al. achieved a 68% union rate with suppressive treat­ment [13]. Implants were removed after union in 40% of the patients. Of the patients that had achieved union with suppressive therapy, recur­rent infection appeared in 36% of patients with retained hardware and 16% in those in whom internal xation had been removed, highlighting the fact that, though bony union is possible, it will not necessarily heal the infection. Berkes et al. similarly found a 71% union rate, but treatment failed signicantly more in open fractures (58% union rate) and those stabilized with intramedul­lary nails (46% union rate) [35]. Remission of infection with retention of intramedullary nails was only achieved in 42% in another series, par­ticularly in infections treated beyond 2 months after implantation [36]. The presence of an intra­medullary nail had an odds ratio of failure of 4.0 (1.1–13.8) in a further series of 141 patients with early FRI treated with DAIR (24% recurrence rate vs. 13% recurrence rate overall) [37]. It would hence seem reasonable to recommend nail exchange in FRI stabilized with intramedullary nails, given the difculty of debriding the medul­lary canal surrounding the nail and the ease of exchange (in comparison with revision of other implants), but a systematic review of 28 studies with 171 FRIs following intramedullary nailing of long bones was unable to nd any differences between treatment strategies for infections up to 9 months after implantation [38]. Tsang et al.