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ICG Fluorescence Imaging in Post-traumatic Infecton

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ClinicalTrials.gov Identifier: NCT04403204
Recruitment Status : Recruiting
First Posted : May 27, 2020
Last Update Posted : January 27, 2022
Sponsor:
Collaborators:
Dartmouth College
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Brigham and Women's Hospital
University of California, Irvine
University of Maryland, Baltimore
Information provided by (Responsible Party):
Ida Leah Gitajn, Dartmouth-Hitchcock Medical Center

Brief Summary:
The focus of this prospective observational study is to (1) establish the range and variation associated with bone/soft tissue perfusion in fracture patients, using ICG fluorescence imaging; (2) examine the relationship between perfusion and complications such as surgical site infection (SSI), persistent SSI, and fracture nonunion; (3) to determine whether the quantitative ICG fluorescence can be used to guide bony debridement in the setting of infected fracture to minimize complications.

Condition or disease Intervention/treatment
Trauma Injury Other: Immunofluorescence Imaging Other: DCE-MRI

Detailed Description:

This will be a prospective observational trial to better understand the range and variation associated with bone/soft tissue perfusion in fracture patients and examine the relationship between perfusion, measured using quantitative Indocyanine green (ICG) fluorescence and complications such as surgical site infection (SSI), persistent SSI, and fracture nonunion. Primary outcome measure is complication (either infection, recurrent infection or nonunion).

Eligible consenting patients will receive standard of care treatment for their fracture or infection including irrigation and debridement of their operative site and/or fracture fixation. After exposure, 0.1 mg/Kg ICG will be injected intravenously and video rate ICG fluorescence images will be acquired 20 seconds before and 4 minutes after the injection, each before and after debridement.

A subset of 30 post-fracture complication patients will undergo surgical treatment for their infection in Center of Innovation Surgery (CIS) and have either an intraoperative Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) after exposure but before the ICG injection or a preoperative DCE-MRI. Patients receiving surgery in the CIS will be required to sign an additional CIS-specific consent document.

The need for repeat surgical procedure will be left up to the treating surgeon. If repeat procedure is needed, pre- and post-debridement quantitative ICG fluorescence images will be obtained at each procedure.

Study participants will be followed at 2 weeks, 6 weeks, 3 months, 6 months, and one year from their index study surgery. Complication including index infection, recurrent infection or delaying union/nonunion will be identified at the time of diagnosis and/or during each participants assessment that occurs during routine outpatient clinic visit. Detailed information on the infection including date of diagnosis, participant signs and symptoms, culture test results, method of treatment(s), and date of resolution will be documented.

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Study Type : Observational [Patient Registry]
Estimated Enrollment : 358 participants
Observational Model: Cohort
Time Perspective: Prospective
Target Follow-Up Duration: 1 Year
Official Title: Real-time Fluorescence-based Measurement of Bone Perfusion in Post-traumatic Infection
Actual Study Start Date : September 14, 2020
Estimated Primary Completion Date : May 31, 2024
Estimated Study Completion Date : May 31, 2025

Resource links provided by the National Library of Medicine


Group/Cohort Intervention/treatment
Established SSI Fracture Cohort
Patients 18 years of age or older. Extremity fracture. Prior definitive fracture management with external fixation, internal fixation, or joint fusion. Superficial, deep, or organ space SSI (as per CDC criteria) at the fracture site that requires operative management. Will have all fracture care surgeries performed by a participating surgeon or delegate. Provision of informed consent
Other: Immunofluorescence Imaging
Patients will be administered FDA approved ICG through intravenous injection and imaged by a FDA approved surgical microscope (Spy Elite) which is 0.5 meter away from the subject. Both ICG fluorescence and the two imaging systems have been used for routine clinical practice for many years. Figure (a) shows the Schematic sketch of the imaging systems. ICG fluorescence imaging utilizes intravenously injected ICG, which is a fluorescent dye that is FDA-approved for clinical use, illuminated with near-infrared light. The ICG dye is indirectly activated and the dynamic fluorescence due to bone perfusion can be captured by a video rate imaging system.

Established SSI Fracture Cohort Subset (DCE-MRI)
Patients 18 years of age or older. Extremity fracture. Prior definitive fracture management with external fixation, internal fixation, or joint fusion. Superficial, deep, or organ space SSI (as per CDC criteria) at the fracture site that requires operative management. Will have all fracture care surgeries performed by a participating surgeon or delegate. Provision of informed consent
Other: Immunofluorescence Imaging
Patients will be administered FDA approved ICG through intravenous injection and imaged by a FDA approved surgical microscope (Spy Elite) which is 0.5 meter away from the subject. Both ICG fluorescence and the two imaging systems have been used for routine clinical practice for many years. Figure (a) shows the Schematic sketch of the imaging systems. ICG fluorescence imaging utilizes intravenously injected ICG, which is a fluorescent dye that is FDA-approved for clinical use, illuminated with near-infrared light. The ICG dye is indirectly activated and the dynamic fluorescence due to bone perfusion can be captured by a video rate imaging system.

Other: DCE-MRI
Characterize the relationship between bone perfusion as quantified by ICG based DCE-FI and DCE-MRI in human patients to develop an accurate depth-sensitive fluorescence imaging model that will correct for the surface-weighted feature of fluorescence imaging




Primary Outcome Measures :
  1. Number of patients experiencing post procedure surgical site infections [ Time Frame: 1 year ]
    Post-procedure surgical site infection using CDC criteria will be documented at each follow-up appointment up to one year

  2. Number of patients requiring unplanned fracture-related reoperations [ Time Frame: 1 year ]
    All unplanned reoperations will be documented



Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Sampling Method:   Non-Probability Sample
Study Population
Patients 18 years of age or older who present with SSI following fracture or joint fusion Established SSI fracture cohort (Cohort 1). A subset of Cohort 1 will be considered for the Subset DCE-MRI cohort (Cohort 1-1).
Criteria

Inclusion Criteria:

Established SSI Fracture (Cohort Cohort 1, Group 1)

  1. Patients 18 years of age or older.
  2. Extremity fracture.
  3. Prior definitive fracture management with external fixation, internal fixation, or joint fusion.
  4. Superficial, deep, or organ space SSI (as per CDC criteria) at the fracture site that requires operative management.
  5. Will have all fracture care surgeries performed by a participating surgeon or delegate.
  6. Provision of informed consent.

Subset: DCE-MRI (Cohort 1-1, Group 2)

  1. Patients 18 years of age or older.
  2. Closed extremity fracture.
  3. Planned definitive fracture management with external fixation, internal fixation, or joint fusion.
  4. Will have all planned fracture care surgeries performed by a participating surgeon or delegate.
  5. Provision of informed consent.

Exclusion Criteria:

Established SSI Fracture Cohort (Cohort 1, Group 1)

  1. Fracture of the hand.
  2. Iodine allergy.
  3. Received previous surgical debridement to manage the SSI.
  4. Incarceration.
  5. Problems, in the judgment of study personnel, with maintaining follow-up with the patient.

    Subset: DCE-MRI (Cohort 1-1, Group2)

  6. the presence of an electronic implant, such as a pacemaker
  7. the presence of a metal implant, such as an aneurysm clip
  8. the presence of other contraindication(s), as determined by the MRI technologists and radiologists.
  9. A history of allergy to iodides
  10. A GFR < 30 ml/min as determined by blood test on the day of NIR/MR imaging, or from lab results within 3 months of DCE-MRI for this study

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT04403204


Contacts
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Contact: Melanie L Christian 603-650-3556 melanie.l.christian@hitchcock.org

Locations
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United States, California
University of California, Irvine Recruiting
Irvine, California, United States, 92614
Contact: Susan Demas    714-456-7710    sdemas@hs.uci.edu   
Principal Investigator: John Scolaro, MD         
United States, Maryland
University of Maryland, Baltimore R. Adams Cowley Shock Trauma Recruiting
Baltimore, Maryland, United States, 21201
Contact: Heather Phipps    410-706-7180    hphipps@som.umaryland.edu   
Principal Investigator: Gerard Slobogean, MD         
United States, Massachusetts
Brigham and Women's Hospital Recruiting
Boston, Massachusetts, United States, 02115
Contact: Abigail Sagona    617-732-5322    asagona@bwh.harvard.edu   
Principal Investigator: Michael J Weaver, MD         
United States, New Hampshire
Dartmouth Hitchcock Medical Center Recruiting
Lebanon, New Hampshire, United States, 03756
Contact: Ida L Gitajn, MD    603-650-5000    ida.l.gitajn@hitchcock.org   
Contact: Melanie L Christian    603-650-3556    melanie.l.christian@hitchcock.org   
Sponsors and Collaborators
Dartmouth-Hitchcock Medical Center
Dartmouth College
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Brigham and Women's Hospital
University of California, Irvine
University of Maryland, Baltimore
Investigators
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Principal Investigator: Ida L Gitajn, MD Dartmouth-Hitchcock Medical Center
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Responsible Party: Ida Leah Gitajn, Physician, Dartmouth-Hitchcock Medical Center
ClinicalTrials.gov Identifier: NCT04403204    
Other Study ID Numbers: D20057
1R01AR077157-01 ( U.S. NIH Grant/Contract )
First Posted: May 27, 2020    Key Record Dates
Last Update Posted: January 27, 2022
Last Verified: January 2022
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Keywords provided by Ida Leah Gitajn, Dartmouth-Hitchcock Medical Center:
Immunofluorescence
Orthopaedic
Trauma
Infection