The work, published in the Journal of Bone and Joint Infection, was coordinated through the African Bone and Joint Infection Network under the auspices of the European Bone and Joint Infection Society, with support from the AO Alliance. Led by Loïc Fonkoué of Yaoundé General Hospital in Cameroon and Elizabeth Tissingh of King’s College London, the group spanned 14 countries, from Ethiopia and Malawi to Switzerland and the United Kingdom. Every member had direct experience treating bone and joint infections in resource-limited environments, a deliberate design choice meant to ensure the recommendations reflect clinical reality rather than idealized conditions.

The recommendations were built through a three-step process. First, two 34-item questionnaires were distributed to network members in November 2024, gathering responses from 86 clinicians in 22 countries about their current practice and their most urgent needs. Second, a one-day consensus meeting was held during the annual congress of the College of Surgeons of East Central and Southern Africa in Harare, Zimbabwe, in December 2024, where a draft document was agreed upon. Third, the wider panel conducted an iterative collaborative review from December 2024 to February 2025, revising recommendations until broad agreement was reached. Notably, the group did not use formal voting or evidence grading, acknowledging that the evidence base from low-income settings is too thin for such methods.

A central technical point of the guidance is terminology and diagnosis. The experts endorse the term fracture-related infection, or FRI, which supersedes older labels such as post-traumatic osteomyelitis and fracture-fixation-associated infection. Because it is impossible to reliably distinguish deep from superficial infection after a fracture, any surgical-site infection following a fracture is considered an FRI. Diagnosis should rest primarily on clinical criteria: sinus tracts, purulence, wound breakdown, and delayed or failed bone healing all warrant suspicion. This emphasis matters because late presentation is common in low-resource settings, and by the time patients arrive, the classic confirmatory signs are often the only reliable indicators available.

The guidelines are equally pragmatic about laboratory and imaging resources. Wound swabs and sinus tract samples are explicitly discouraged for microbiological culture, since they tend to grow skin commensals that do not represent the true pathogen. Instead, intra-operative tissue sampling is the diagnostic test of choice: five samples taken with separate clean instruments raise diagnostic yield to 97 percent, compared with 84 percent for three samples, though three samples are deemed acceptable under constraint. Routine X-rays should be prioritized over costly CT, MRI, or nuclear imaging, which are helpful but not essential. Histology offers a low-cost adjunct, with more than five neutrophils per high-power field considered significant, a technique accessible even in laboratories that mainly process malaria blood films.

Perhaps the most striking technical content concerns antibiotic strategy. Data from Cameroon and Nigeria show that Gram-negative bacteria account for 65.8 percent and 49 percent of fracture-related infections respectively, a markedly different profile from high-income countries where Staphylococcus aureus dominates. The experts therefore recommend empirical therapy combining a glycopeptide, such as vancomycin, with an agent active against Gram-negatives, such as amikacin or meropenem, with cefazolin plus gentamicin as a fallback. For definitive oral therapy, they favor bactericidal drugs with high oral bioavailability and good bone penetration, including rifampicin, fluoroquinolones, clindamycin, and fosfomycin, while cautioning against cephalosporins for oral use and against the rifampicin-clindamycin combination, which risks inducible resistance.

Local antibiotic delivery receives detailed attention because it demonstrably works: in a study of 433 confirmed infections, adding local antibiotics to definitive management cut failure rates from 18.3 percent to 10.3 percent. Polymethylmethacrylate cement, readily available and affordable across Africa, can be fashioned into spacers or beads, though it requires removal surgery and has poorer drug elution than absorbable calcium sulfate and composite ceramic carriers. The guidelines also flag a practical dilemma: rifampicin, the cornerstone of anti-biofilm therapy for implant retention, is often restricted to tuberculosis treatment programs in African countries. Encouragingly, evidence from the SOLARIO trial suggests that when local antibiotic carriers are used, as little as seven days of systemic therapy may suffice, a finding with major implications for adherence and antimicrobial stewardship.

On the surgical side, the recommendations preserve the universal principles of meticulous debridement of dead tissue until punctate bleeding appears, copious low-pressure saline irrigation without additives, and rigid fracture stabilization. But they also codify resource-adapted innovations. Where patients cannot afford a new implant, the group endorses debridement and implant sterilization, in which the removed hardware is re-sterilized and reused during the same operation. Debridement and implant retention is favored for early infections when fixation is stable, since implants are scarce. For dead-space management, options range from the induced-membrane Masquelet technique with cement to antibiotic-impregnated bone autografts and bone transport using external frames. The group also warns against prolonged vacuum-assisted dressings, citing evidence that negative pressure wound therapy more than doubles recurrence risk in fracture-related infection.

Prevention and system-level reform round out the guidance. Improved early management of open fractures, which can become infected in up to 52 percent of cases in some series, is identified as the single most effective strategy for reducing the disease burden, alongside WHO surgical safety checklists, engagement with community leaders and traditional bone setters to reduce treatment delays, and optimization of comorbidities including HIV, diabetes, anemia, and malnutrition. The recommendations have been packaged as the seventh ACTIONS guideline, part of the African Consensus for Trauma in Orthopaedics: National Standards series, and are available in English, French, and Portuguese to maximize uptake across the continent.

The authors are candid about the limitations: much of the guidance rests on expert consensus rather than trials conducted in the settings it targets, and urgent research priorities include building treatment networks, defining optimal antibiotic regimens and sampling protocols, and establishing supply chains for local antibiotic carriers and circular fixators. They call on ministries of health, clinicians, and industry to invest in training, reconstructive capacity, and diagnostics. The guidelines do not replace international standards, the authors stress; rather, they translate essential principles into feasible strategies for the hospitals where the burden of bone infection is greatest, while insisting that robust audit and locally generated evidence will be needed to refine them for the future.

Subject of Research: Consensus guidelines for managing fracture-related infection in low-resource settings in Africa

Article Title: Management of fracture-related infection in low-resource settings in Africa: recommendations and guidelines from an international expert group

Article References: Fonkoué, L., Tissingh, E. K., Marais, L. C., Malaba, M., Abrha, K., Ferguson, J., Morgenstern, M., Cornu, O., Laubscher, M., Buzisa Mbuku, R., Galiwango, G. W., Botman, M., Wojno, J., Majigo, M. V., Martin Jr., C., Harrison, W. J., Schade, A. T., Marenah, K., Nyamutora, M., … McNally, M. (2026). Management of fracture-related infection in low-resource settings in Africa: recommendations and guidelines from an international expert group. Journal of Bone and Joint Infection, 11(4), 401-411. https://doi.org/10.5194/jbji-11-401-2026

Image Credits: AI Generated

DOI: 10.5194/jbji-11-401-2026

Keywords: fracture-related infection, osteomyelitis, low-resource settings, Africa, orthopaedic surgery, antibiotic stewardship, consensus guidelines, global health, surgical infection, open fractures, microbiology, AO Alliance

The clinical problem the surgeons confronted is enormous. Lower extremity injuries, particularly those caused by road traffic accidents, are the second leading cause of morbidity and mortality in Kenya, and open fractures with extensive soft tissue loss are among the most difficult injuries in all of trauma surgery. These are dynamic wounds that evolve over hours after the initial insult, and their management demands a multidisciplinary approach involving both orthopaedic and plastic surgeons, rigorous infection control, skeletal stabilization, and ultimately durable soft tissue coverage. When local tissue is insufficient to cover exposed bone, tendons, and hardware, the gold standard is free tissue transfer: harvesting a segment of muscle or skin, along with its artery and vein, from a distant part of the body and reconnecting its blood vessels to vessels at the recipient site under magnification.

Free flap surgery of this kind routinely achieves success rates exceeding 90 per cent in high-income countries, and it has measurably reduced amputation rates for severely injured limbs. Yet the barriers to replicating these outcomes in low- and middle-income countries are formidable. Operating microscopes are expensive to purchase and maintain, microsurgical instruments are costly, and trained microsurgeons are scarce. Many reconstructive units in sub-Saharan Africa lack access to even the basic infrastructure required, and patients frequently receive suboptimal treatment, delayed referrals, or primary amputation as the default option. The Kenyan team set out to show what is achievable when a well-equipped tertiary centre, staffed by experienced microsurgeons, exists within an otherwise resource-limited system.

The series comprised fourteen adult patients, ten male and four female, all of whom underwent lower extremity free flap reconstruction with at least one month of follow-up. Eleven had Gustilo-Anderson type 2-3b open fractures, two had degloving injuries in which skin and underlying tissue were torn away from the limb, and one required reconstruction after removal of a tumour of the hallux, the big toe. Preoperative vascular assessment included computed tomography angiography and handheld Doppler ultrasonography—diagnostic resources that are rarely available in comparable settings and that proved critical for mapping recipient vessels before the operating room. All procedures were performed by a consultant microsurgeon at a Level 1 trauma facility, under general anaesthesia, with wound debridement conducted under tourniquet control.

The technical details of the operations reveal the precision the procedure demands. Fasciocutaneous free flaps, which carry skin and its underlying fascia, were used in nine patients, while muscle flaps were used in five. Recipient vessels were selected according to wound configuration, local anatomy, and the mechanism of injury, with surgeons carefully examining the vessel wall, the extent of injury, and the quality of the adventitia before committing to an anastomosis. Crucially, all arterial connections were performed proximal to the zone of injury, following the principle that vessels damaged by trauma provide unreliable inflow. Thirteen cases used end-to-end anastomoses to the anterior tibial artery, the dorsalis pedis artery, or the superior medial genicular artery, while one case used an end-to-side connection to the posterior tibial artery. Where a surgical microscope was unavailable, surgeons achieved comparable results using loupe magnification in five cases.

The case series includes vivid individual examples that illustrate the range of reconstructive options. One middle-aged woman suffered a left ankle degloving injury, a distal tibia fracture, and complex bilateral midfoot fracture-dislocations in a road traffic accident. After initial washout, external fixation, and vacuum-assisted closure dressings, the team performed delayed definitive closure using a free gracilis muscle flap—the posterior-most adductor muscle of the thigh, supplied by the medial circumflex femoral artery with a pedicle roughly seven centimetres long—combined with a skin graft and internal fixation of the fractures. A two-team approach allowed simultaneous harvest and recipient-site preparation, shortening operative time and reducing donor-site morbidity. The flap integrated fully, with satisfactory functional and aesthetic outcomes at follow-up.

Another patient, a soldier with blast injuries to the right foot, presented with segmented fractures of the metatarsals and midfoot bones, bony defects at the second and third metatarsals, and loss of Lisfranc alignment. After debridement, K-wire stabilization, and temporary vacuum dressings, the surgeons planned a latissimus dorsi free muscle flap based on the thoracodorsal artery, whose single dominant pedicle can reach twelve centimetres in length and 2.5 millimetres in diameter. The flap was designed with a lazy-S skin paddle oriented along the pedicle, the serratus branch was preserved for venous anastomosis, and intraoperative imaging confirmed the muscle flap in place alongside antibiotic bone cement. A third patient, who developed chronic osteomyelitis after a high-energy motor vehicle collision, underwent a first-stage Masquelet procedure with a cement spacer and soft tissue coverage using a parascapular free flap harvested through the triangular space of the back. A fourth, whose foot was crushed in an industrial accident, received a free anterolateral thigh flap over a transmetatarsal amputation stump, with a total ischemic time of just one hour.

Postoperative care followed a rigorous, standardized protocol. Patients were admitted to the critical care unit for forty-eight hours, where flaps were assessed hourly by an attending consultant and a senior registrar, with checks of colour, capillary refill, temperature, and Doppler signals to detect early vascular compromise. Venous thromboembolism prophylaxis consisted of enoxaparin 40 milligrams subcutaneously once daily, alongside aspirin 75 milligrams, and limbs were elevated and immobilized in splints. Mobilization began on postoperative day five with individualized protocols and compression bandaging. This intensity of monitoring is itself notable: in many low-resource settings, patients are not routinely admitted to critical care, and flaps are monitored on general wards using clinical parameters alone, including pinprick testing for bleeding quality.

Outcomes were strong but not flawless. Twelve of the fourteen flaps survived without complication. Two flaps failed—one attributed to suspected underlying peripheral arterial disease, detected intraoperatively as weak dorsalis pedis flow and dark venous bleeding despite an intact pedicle, and the other to multifactorial causes—both necessitating debridement and skin graft reconstruction. Definitive management ranged from ten to fifty-six days, with an average hospital stay of two to three weeks. All patients completed at least one month of follow-up without delayed flap failures. The authors acknowledge limitations, including the absence of diagnostic angiograms for preoperative detection of peripheral arterial disease, the inability to formally assess functional outcomes, and loss of some patients to long-term follow-up.

The broader significance of the study lies in what it suggests about global surgical equity. The flap survival rates achieved in Nairobi matched those reported in high-income countries, demonstrating that successful microsurgical reconstruction is possible in resource-limited settings when expertise and infrastructure converge in a well-equipped tertiary centre. The authors argue that expanding fellowship opportunities for reconstructive surgeons in low- and middle-income countries is essential, and that surgeons returning from such training can practise microsurgical techniques using basic materials and shared local resources. They also call for structured retrospective and prospective observational studies to build the evidence base further. For the millions of patients worldwide who suffer devastating limb injuries each year, the message is clear: the decision between salvage and amputation should depend on clinical factors and access to skilled teams—not on geography or the wealth of the health system a patient happens to be born into.

Subject of Research: Lower extremity free flap reconstruction for traumatic limb injuries in a resource-limited health system

Article Title: Lower extremity free flap reconstructions in a tertiary trauma centre within a resource-limited health system: a case series

Article References: Otieno, D. O., Okello, A. W., Gathura, E. W., Gebremariyam, Z. T., Nang’ole, F. W., Sulemanji, D. S., & Wabwire, B. (2026). Lower extremity free flap reconstructions in a tertiary trauma centre within a resource-limited health system: a case series. BMC Plastic and Reconstructive Surgery, 2(1), Article 3. https://doi.org/10.1186/s44452-026-00015-x

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00015-x

Keywords: free flap reconstruction, microsurgery, lower extremity trauma, limb salvage, resource-limited settings, Kenya, open fractures, reconstructive surgery, trauma surgery, fasciocutaneous flaps, muscle flaps, global surgery