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Ste phen L Kate s | Olivie r Borens

Principle s of Orthope dic Infe ction

Management
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Ste phen L Kate s | Olivie r Borens

Principle s of Orthope dic Infe ction

Management

Include s 6 vide os and ove r 8 0 0 im age s and illustrations

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Distribution by Ge org Thie m e Ve rlag, Rdige rstrasse 14 , 70 4 69 Stuttgart, Ge rm any, and Thie m e Ne w York, 3 33 Se ve nth Ave nue , Ne w York, NY 10 0 01, USA
ISBN: 978 -3 -13 -2410 75 -6
e -ISBN: 978 -3 -13 -241076 -3
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Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Fore word
Foreword
Wh en th e AO Fou n dation w as ou n ded in Sw itzerlan d in
1958, a revolu tion began in th e m an agem en t o ractu res.
Sim ilarly, h ip join t replacem en t w as a m ajor breakth rou gh
in th e treatm en t o osteoarth ritis. Un ortu n ately, orth opedic
im plan t-associated in ection th en becam e a seriou s problem
com prom isin g u n ction al resu lts. Han s Willen egger, on e o
th e ve ou n ders o AO, th ere ore dedicated a sign i can t
part o h is career to stu dyin g th e m an agem en t o com plica-
tion s ollowin g in tern al bon e xation . He an d oth ers rapidly
realized th at im plan t m aterial as w ell as th e bon e sequ esters
in creased su sceptibility to in ection an d prom oted m icrobial
persisten ce on n on vital su r aces.
In itially, th e th erapeu tic approach w as m ain ly su rgical. It
h as been recogn ized th at n ot on ly th e degree o severity o
th e trau m a, bu t also th e type o bon e xation in f u en ce th e
pattern o bon e n ecrosis in a typical w ay. Th e pillars o su r-
gical treatm en t w ere th en de n ed as:
Debridem en t o n ecrotic bon e an d so t tissu e
Rem oval o im plan t m aterial
Osteoplastic m easu res su ch as au togen ou s bon e gra tin g
In case o ailu re, in ected n on u n ion s becam e an im portan t
su bject. Un ortu n ately, even addin g system ic an tibiotics or
an tiseptics ailed to resu lt in reliable h ealin g o posttrau -
m atic osteom yelitis. Su ccess rates rem ain ed low, th e n u m ber
o requ ired su rgical in terven tion s h igh , an d late recu rren ce
w as rath er requ en t.
A ew dedicated m icrobiologists an d in ectiou s disease spe-
cialists dem on strated th at m icroorgan ism s persist as bio lm
on im plan ts, an d w ith stan d n ot on ly h ost de en ces bu t also
m ost an tim icrobial agen ts. It w as observed th at th e e cacy
o an an tibiotic in im plan t-associated in ection requ ired
activity on n on grow in g bacteria. Fu rth erm ore, it cou ld be
sh ow n th at even su ch an tibiotics act on ly on you n g bio lm s.
Based on th ese observation s, treatm en t algorith m s w ere
developed or th e m an agem en t o im plan t-associated os-
teom yelitis an d periprosth etic join t in ection .
Over th e last tw o decades, it h as been realized th at th e
treatm en t su ccess o orth opedic im plan t-associated in ection
h as been h eavily depen den t on correct m an agem en t. Th u s,
a dedicated team o orth opedic su rgeon s, in ectiou s disease
specialists, m icrobiologists, plastic su rgeon s, an d path ologists
are n ow requ ired or optim al treatm en t resu lts. It is an im -
portan t m essage rom th is book to train su ch specialized
team s to im prove th e su ccess rate o orth opedic im plan t-
associated in ection treatm en t.
Th is book gives an overview o th e im portan t eld o orth o-
pedic in ection . Th e rst section deals w ith th e basic prin -
ciples o su ch in ection s. Th ese prin ciples acilitate th e
u n derstan din g o path ogen esis, diagn osis, an d m an agem en t
o in ection s o th e m u scu loskeletal system . It becam e clear
th at th erapeu tic su ccess can on ly be con sidered a ter 12
years, th ere ore, patien ts m u st be ollow ed u p or at least
th is period o tim e to rapidly diagn ose an d treat an y pos-
sible recu rren ces, an d to evalu ate th e treatm en t resu lts o
a coh ort. Th e secon d section o th e book deals w ith th e
di eren t types o in ection s an d o ers speci c advice on
h ow to m an age a variety o situ ation s. In th e th ird section ,
typical case exam ples allow th e reader to see h ow th e kn ow l-
edge explain ed in th e precedin g ch apters w orks in practice.
Th ese case exam ples h elp th e reader to get an im pression
o th e reason in g o th e specialists in m an agin g su ch in ection s.
A collaboration n early as lon g as th eir pro ession al lives
lin ks th e au th ors o th is Forew ord in th e treatm en t o m u s-
cu loskeletal in ection s. We h ave realized th at by doin g so,
th e m u tu al prom otion o kn ow ledge in th e eld con tin u es
to grow. We are con vin ced th at u rth er progress can on ly
be ach ieved by th e con stan t acqu isition o n ew elds o
kn ow ledge. It is u p to you to devote you rsel to th is task.
Peter E. Och sn er, MD Wern er Zim m erli, MD
Orth opedic su rgeon In ectiou s diseases specialist
V
 Fore word
Foreword
Th e au th ors are to be con gratu lated th is book is a m u st
or an yon e treatin g th e m u scu loskeletal system , an d espe-
cially so or su rgeon s. Th ere are m an y com plication s in
m edicin e, as in li e, bu t or a su rgeon , in ection is th e m ost
dreaded an d especially so w h en it is iatrogen ic, ie, w e are
respon sible! Th is treatise is rem arkable as it is so com pre-
h en sive, coverin g th e basics, th e scien ce, organ ism s, h ow
th ey colon ize, m u ltiply, bio lm , an d even th e h ost respon se.
Th is is ollow ed by tech n iqu es an d algorith m s or diagn osis,
treatm en t prin ciples, an d an tibiotics, an d h ow th ese are
applied to su rgical situ ation s in clu din g acu te an d ch ron ic
in ection s, post ractu re/ n on u n ion , an d oth er orth opedic
im plan t su rgeries in volvin g arth roplasty, th e spin e, sports
in ju ries, open ractu res, an d w ou n ds. Fin ally, th ere is a lon g
list o case exam ples o com m on in ectiou s scen arios in -
volvin g th e m u scu loskeletal system .
Th is book is an u n believable resou rce or an y su rgeon , n ot
on ly to treat an d m an age m u scu loskeletal in ection s, bu t
better still to u n derstan d w h y an d h ope u lly preven t su ch
rom h appen in g in th e u tu re.
David L Hel et, MD
Pro essor o Orth opaedic Su rgery
Weill Medical College o Corn ell Un iversity
Director, Orth opaedic Trau m a Service
Hospital or Special Su rgery/ New York Presbyterian Hospital
VI
Preface
Wh en servin g as ch airs an d acu lty o variou s AOTrau m a
cou rses on in ection over th e years, w e h ave h ad th e
opportu n ity to get to kn ow each oth er an d to sh are ou r
kn ow ledge an d th ou gh ts abou t th e th in gs th at a ect ou r
daily practice. Du rin g on e sn ow y a tern oon in Decem ber,
w e realized th at despite ou r sh ared con cern over th e im pact
o in ection on ou r patien ts an d th eir am ilies, th ere w as
very little literatu re an d in deed n o orth opedic text book
th at covered th e sorts o th in gs w e elt w ere im portan t. Few
books really dealt w ith th e problem adequ ately, an d m an y
w ere w ritten speci cally or an d by in ection specialists. No
book really com bin ed th e daily practical n eeds o both th e
su rgeon an d th e in ection specialist.
It w as ou r great pleasu re th en to be able to liaise w ith
m edical colleagu es an d edu cation experts to propose th e
developm en t o th is text at a tim e w h en in ection h ad com e
to ligh t as a critical an d h igh ly overlooked actor in orth o-
pedic treatm en t. We especially w an ted to en su re th ere w as
a ocu s on a team approach to treatin g in ection , in volvin g
m icrobiologists, orth opedic su rgeon s, an d in ection special-
ists. Ou r m ain goal or th e book w as to provide a basic
kn ow ledge or all o th ese pro ession als on h ow to approach
th e problem , an d equ ally im portan tly, on h ow to preven t it.
We are extrem ely pleased th at w e w ere able to in volve
opin ion leaders rom a w ide ran ge o elds an d specialties
to join u s an d con tribu te to th e book. We w ere especially
m otivated to en su re th at th e book o ered th e reader a prac-
tical approach to in ection treatm en t, w ith m an y real patien t
cases on h ow th e au th ors treated th eir ow n orth opedic
in ection ch allen ges.
In terest in th e topic o in ection is in creasin g dram atically,
an d w e n ote th e AO h as greatly in creased th e n u m ber o
cou rses an d oth er edu cation al activities coverin g th is topic
in recen t years. We are extrem ely prou d to be at th e ore ron t
o th is n ew ocu s, an d to be able to gen u in ely recom m en d
th is book to ou r colleagu es an d cou n terparts in volved in
research in g, an alyzin g, or treatin g orth opedic in ection .
Steph en L Kates
Olivier Boren s
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Acknowle dgme nts
Acknowledgments
Produ ction an d pu blication o th e Prin ciples o Orth opedic
In ection Man agem en t wou ld n ot h ave been possible with ou t
th e dedication an d su pport o an exten sive list o con tribu -
tors. From AO su rgeon s don atin g th eir tim e w ith in th e
variou s edu cation com m ittees an d w orkin g grou ps, to ou r
m an y colleagu es th at volu n teered case n otes an d im ages,
to sta w ith in ou r ow n m edical practices, an d to th e team s
at AOTrau m a an d AO Edu cation In stitu te, w e th an k you
or assistin g u s to develop th is w orth w h ile pu blication .
Wh ile th ere are m an y people to th an k, w e w ou ld especially
like to m en tion th ese in dividu als:
Kodi Kojim a an d th e oth er m em bers o th e AOTrau m a
Edu cation Com m ission , or recogn izin g th e edu cation al
opportu n ity an d or providin g th e resou rces in approv-
in g th e developm en t o th is pu blication
Urs R etsch i, Robin Green e, an d Mich ael Cu n n in gh am
rom th e AO Edu cation In stitu te, or th eir gu idan ce
an d expertise, an d or en ablin g exten sive resou rces an d
sta to prepare th is pu blication to its u llest capacity
Th e au th ors, ou r colleagu es rom arou n d th e w orld,
w h o don ated m an y h ou rs to provide ch apters, cases,
an d im ages, an d also to th ose n ot even in volved
speci cally w ith th is w ork, bu t w h o oth erw ise sh are in
th e spirit o ratern ity w h en it com es to edu cation an d
train in g
David Hel et, Peter Och sn er, an d Wern er Zim m erli or
w ritin g th e Forew ords to th is book
Carl Lau , Man ager Pu blish in g an d Am ber Parkin son ,
Project Man ager or th eir pro ession al su pport
Jecca Reich m u th , Tam ara Aepli, an d Rol Joray
(Nou gat design ) or th eir illu stration w ork
Tom Wirth rom Nou gat design an d Rom an Kellen berger,
th e graph ic design ers, respon sible or th e overall layou t
o th is book an d or takin g in th e m an y rou n ds o
editorial correction s
Mike Law s an d Th om as Lopath ka or th eir expertise
an d assistan ce in produ cin g th e videos
An d lastly, to ou r ow n am ilies or th eir su pport an d
en cou ragem en t th rou gh ou t th is project.
Steph en L Kates
Olivier Boren s
VII
 Contributors

Contributors

Ed it o rs

Stephen L Kates, MD Olivier Borens, MD

Professor and Chair of Orthopaedic Surgery Professor and Mdecin chef
Virginia Commonwealth University Unit de Traumatologie
Richmond, VA23284 Unit de Chirurgie Septique
USA Service d'Orthopdie et de Traumatologie
Bureau BH10-230
Rue du Bugnon 46
1011 Lausanne
Switzerland

Au t h o rs

Volker Alt, Dr med, Dr biol hom Karen Bentley, MS Anna Conen, MD, MSc
Professor Director Deputy Head Physician
Department of Trauma, Hand Electron Microscope Shared Research Laboratory Division of Infectious Diseases and Hospital Hygiene
and Reconstructive Surgery Pathology and Laboratory Medicine Kantonsspital Aarau
University Hospital Giessen-Marburg University of Rochester Medical Center Tellstrasse
Campus Giessen 575 Elmwood Avenue 5001 Aarau
Rudolf-Buchheim-Str. 7 Rochester, NY14642 Switzerland
35385 Giessen USA
Germany Stphane Corvec, PharmD, PhD, HDR
Olivier Borens, MD Associate Professor, MCU-PH
Mathieu Assal, PD Dr med Professor and Mdecin chef Clinical Microbiologist
Clinique La Colline Unit de Traumatologie Nantes University Hospital
Avenue de Beau-Sjour 6 Unit de Chirurgie Septique Bacteriology and Hygiene Department
1206 Genve Service d'Orthopdie et de Traumatologie Biology Institute
Switzerland Bureau BH10-230 9 Quai Moncousu
Rue du Bugnon 46 44093 Nantes, Cedex 01
Jorge Daniel Barla, MD 1011 Lausanne France
Orthopedics Switzerland
Hospital Italiano de Buenos Aires Xavier Crevoisier, PD Dr med
Potosi 4247 Antonia F Chen, MD, MBA Mdecin chef
C1181ACH Buenos Aires Assistant Professor Site Hpital Orthopdique
Argentina Sidney Kimmel Medical College Service d'Orthopdie et de Traumatologie
Associate Director of Research Avenue Pierre Decker 4
Caleb Behrend, MD Rothman Institute 1011 Lausanne
Rothman Institute Thomas Jefferson University Hospital Switzerland
999 Route 73 N, Suite 3RD Philadelphia, PA19107
Marlton, NJ 08053 USA
USA

VIII Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Contributors

John L Daiss, PhD AJ Electricwala, MS, DNB(Orth) Sven Hungerer, PD Dr med

Research Associate Professor Assistant Professor Head of Department for Reconstructive Joint Surgery
Center for Musculoskeletal Research Sancheti Hospital BG Trauma Center Murnau
University of Rochester Medical Center 16 Shivajinagar Professor-Kntscherstr. 8
601 Elmwood Ave, Box 665 Pune 411005 82418 Murnau
Rochester, NY14642 Maharashtra State Germany
USA India
Peter JL Jebson, MD
Craig J Della Valle, MD John C El ar, MD, FACS Instructor, Grand Rapids Medical Education Partners
Professor of Orthopaedic Surgery Director, Hand and Upper Extremity Fellowship Associate Professor
Chief, Division of Adult Reconstructive Surgery Director, Center for Orthopaedic Population Studies Michigan State College of Medicine
Rush University Medical Center Department of Orthopaedics Chief, Department of Orthopedics
1611 West Harrison Street, Suite 300 Division of Sports Medicine Spectrum Health Medical Group
Chicago, IL 60612 University of Rochester Medical Center Chief, Orthopedic Health Clinical Service Line
USA 601 Elmwood Ave Spectrum Health System
Rochester, NY14642 Grand Rapids, MI
Lorenzo Drago, PhD USA USA
Chief of Clinical Chemistry and Microbiology Lab
IRCCS Istituto Ortopedico Galeazzi Alain Farron, MD Christian Kammerlander, PD MD
Via R. Galeazzi 4 Professor Vice Director
20161 Milano Chef de Service Department for General, Trauma
Italy Service d'Orthopdie et de Traumatologie and Reconstructive Surgery
Bureau HO/06/1644 Ludwig Maximilian University Munich
Christopher J Drinkwater, MD, FRACS Avenue Pierre Decker 4 Campus Grosshadern
Chief, Adult Reconstruction Division 1011 Lausanne Marchioninistrasse 15
Director, Evarts Joint Center Switzerland 81377 Munich
Associate Professor of Orthopaedics Germany
University of Rochester Medical Center A Samuel Flemister Jr, MD
601 Elmwood Avenue School of Medicine and Dentistry Stephen L Kates, MD
Rochester, NY14642 University of Rochester Medical Center Professor and Chair of Orthopaedic Surgery
USA 601 Elmwood Ave, Box 665 Virginia Commonwealth University
Rochester, NY14642 Richmond, VA23284
Lisca Drittenbass, Dr med USA USA
Centre de Chirurgie du Pied et de la Cheville
Clinique La Colline Arthur Grzesiak, Dr md Anjan P Kaushik, MD
Avenue de Beau-Sjour 6 Mdecin-hospitalier Attending Physician, Orthopaedic Surgery
1206 Genve Service d'Orthopdie et Traumatologie Hancock Orthopedics
Switzerland Chasseral 20 Hancock Regional Hospital
2300 Chaux-de-Fonds 1 Memorial Square
George SM Dyer, MD, FACS Switzerland Greenfield, IN 46140
Assistant Professor, Orthopaedic Surgery USA
Harvard Medical School Peter J Haar, MD, PhD
Program Director, Harvard Combined Orthopaedic Director of Medical Student Education for Radiology James F Kellam, MD, FRCS(C), FACS, FRCSI(Hon)
Residency Assistant Professor of Radiology UTHealth, The University of Texas
Orthopaedic Upper Extremity Surgeon Virginia Commonwealth University Medical Center McGovern Medical School
Brigham and Women's Hospital 1250 East Marshall Street Department of Orthopaedic Surgery
75 Francis St Richmond, VA23219 6431 Fannin St
Boston, MA02115 USA Houston, TX77030
USA USA

IX
 Contributors

Johan Lammens, MD, PhD Kohei Nishitani, MD PhD Javad Parvizi, MD, FRCS
Professor Staff Physician Director of Clinical Research
Orthopaedic Department Department of Orthopaedic Surgery Rothman Institute
UZ Leuven Graduate School of Medicine Thomas Jefferson University Hospital
Weligerveld 1 Kyoto University Sheridan Building, Suite 1000
3212 Pellenberg 54 Shogoin Kawaharacho 125 S 9th Street
Belgium Sakyo-ku Kyoto 606-8507 Philadelphia, PA19107
Japan USA
Tak-Wing Lau, MBBS, FRCS(Ed) (Orth), FHKAM
(Orth), FHKCOS Peter E Ochsner, Dr med Mara Eugenia Portillo, PhD
Associate Consultant Professor Department of Microbiology
Division of Orthopaedic Trauma Emeritus Extraordinarius in Orthopaedics Complejo Hospitalario de Navarra
Queen Mary Hospital University of Basel C/Irunlarrea
102 Pokfulam Rd Rttigasse 7 31008 Pamplona, Navarra
Pokfulam 4402 Frenkendorf Spain
Hong Kong Switzerland
Virginia Post, PhD
Martin A McNally, MD, FRCS(Ed), FRCS (Orth) Chang-Wug Oh, MD Postdoctoral Research Fellow
The Bone Infection Unit Professor AO Research Institute Davos
Nuffield Orthopaedic Centre Department of Orthopedic Surgery Clavadelerstrasse 8
Oxford University Hospitals Kyungpook National University Hospital 7270 Davos
Windmill Road 50,2-ga, Samdok Switzerland
Oxford OX3 7HE Chunggu
UK Daegu 700-721 R Geo Richards, MSc, PhD, FBSE
Korea Director
Paul W Millhouse, MD, MBA AO Research Institute Davos
Research Fellow Jong-Keon Oh, MD Clavadelerstrasse 8
Thomas Jefferson University Director 7270 Davos
1015 Walnut St, Suite 509 Department of Orthopedic Surgery Switzerland
Philadelphia, PA19107 Korea University Guro Hospital
USA #148, Gurodong-ro, Guro-gu David C Ring, MD, PhD
Seoul 08308 Associate Dean for Comprehensive Care
Mario Morgenstern, Dr med Korea Professor of Surgery
Department of Traumatology The University of Texas at Austin
University Hospital Basel Kailash Patil, MBBS, DOrth, DNB(Orth), MNAMS Dell Medical School
Spitalstrasse 21 Assistant Professor 1400 Barbara Jordan Avenue
4031 Basel Department of Joint Replacement and Sports Injury Suite 1.114
Switzerland Sancheti Institute for Orthopedics Austin, TX78723
and Rehabilitation USA
T Fintan Moriarty, PhD 16 Shivajinagar
Research Scientist Pune 411005 Carlo L Roman, MD
AO Research Institute Davos Maharashtra State Director
Clavadelerstrasse 8 India Centro di Chirurgia Ricostruttiva e delle Infezioni
7270 Davos Osteo-articolari
Switzerland IRCCS Istituto Ortopedico Galeazzi
Via R. Galeazzi 4
20161 Milano
Italy

X Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Contributors

Yoav Rosenthal, MD Theddy Slongo, MD Zhao Xie, MD, PhD

Department of Orthopaedic Surgery Department of Paediatric Surgery, Paediatric Trauma Professor and Vice Director
Rabin Medical Center and Orthopaedics Department of Orthopaedic Surgery
Petah Tikva 49100 University Children's Hospital Southwest Hospital
Israel Freiburgstr. 7 Third Military Medical University
3010 Bern # 30 Gaotanyan St
Luciano Rossi, MD Switzerland 400038 Chongqing
Italian Hospital from Buenos Aires China
Department of Trauma Christoph Sommer, Dr med
Peron 4190 Chefarzt Unfallchirurgie Erlangga Yusu , MSc, MD, PhD
C1199ABB Buenos Aires Departement Chirurgie Department of Medical Microbiology
Argentina Kantonsspital Graubnden and Infection Control
Lostrasse 170 University Hospital Brussels (UZ Brussel)
Parag Sancheti, MS(Orth), DNB(Orth), MCh, 7000 Chur Laarbeeklaan 101
FRCS(Ed) Switzerland 1090 Jette
Professor and Chairman Belgium
Sancheti Institute for Orthopaedics Andrej Trampuz, MD
and Rehabilitation Professor Charalampos G Zalavras, MD, PhD
16 Shivajinagar Center for Septic Surgery Professor of Orthopaedic Surgery
Pune 411005 Charit - University Medicine Berlin Keck School of Medicine
Maharashtra State Campus Virchow-Klinikum University of Southern California
India Mittelallee 4 LAC and USC Medical Center
13353 Berlin 1200 North State Street
Edward M Schwarz, PhD Germany Los Angeles, CA90033
Professor of Orthopaedics USA
Director, Center for Musculoskeletal Research Alexander R Vaccaro, MD, PhD
University of Rochester Medical Center Rothman Institute Michael J Zegg, MD
601 Elmwood Avenue 925 Chestnut Street Department for Trauma Surgery
Rochester, NY14642 Philadelphia, PA19107 University Hospital Innsbruck
USA USA Anichstrasse 35
6020 Innsbruck
Parham Sendi, MD Steven Velkes, MBChB Austria
Lecturer in Infectious Diseases Head of Orthopedic Surgery
Department of Infectious Diseases Rabin Medical Center Werner Zimmerli, MD
Bern University Hospital Petah Tikva 49100 Professor in Internal Medicine
University of Bern Israel and Infectious Diseases
3010 Bern Interdisciplinary Unit for Orthopaedic Infections
Switzerland Josephina A Vossen, MD, PhD Kantonsspital Baselland
Assistant Professor Rheinstrasse 26
Ashok Shyam, MBBS, MS(Orth) MCVHospitals and Physicians 4410 Liestal
Consultant Orthopaedic Surgeon and Research Head VCU Health System Switzerland
Sancheti Institute for Orthopaedics 1250 E Marshall St
and Rehabilitation Richmond, VA23298 Matthias A Zumstein, PD Dr med
16 Shivajinagar USA Section Head
Pune 411005 Shoulder, Elbow and Sports Medicine
Maharashtra State Department of Orthopaedics and Traumatology
India University of Bern, Inselspital
3010 Bern
Switzerland

XI
 Table of conte nts

Se ct io n 2
Front matter Spe cial situations
Fo re wo rd V 8 Op e n fractu re s
Charalam pos G Zalavras 123
Pre face VI
9.1 In fe ctio n a fte r fra ctu re
Ackn o w le d gm e n ts VII
Martin A McNally 139
Co n trib u to rs VIII
9.2 In fe cte d n o n u n io n
Johan Lamm ens, Peter E Ochsner, Martin A McNally 167

Se ct io n 1 10 In fe ctio n a fte r jo in t a rth ro p la st y

Antonia F Chen, Carlo L Rom an, Lorenzo Drago, Javad Parvizi 189
Principle s 11.1 Se p tic a rth ritis
Anna Conen, Olivier Borens 213
1 Im p la n t-a sso cia te d b io lm
11.2 Se p tic a rth ritis a fte r a n te rio r cru cia te
Kohei Nishitani, Karen de Mesy Bentley, John L Daiss 3
liga m e n t su rge ry
2 Ho st im m u n it y Parag Sancheti, AJ Electricwala, Ashok Shyam , Kailash Patil 227
John L Daiss, Edward M Schwarz 19
12 Sp o n d ylo d iscitis
3 Micro b io lo gy Paul W Millhouse, Caleb Behrend, Alexander R Vaccaro 235
Virginia Post, R Geoff Richards, T Fintan Moriarty 29
13 So ft-tissu e in fe ctio n s
4 Pre ve n tio n o f in tra o p e ra tive in fe ctio n Sven Hungerer, Mario Morgenstern 245
Erlangga Yusuf, Olivier Borens 45
14 Op e n w o u n d s
5 Syste m ic an tib io tics Jorge Daniel Barla, Luciano Rossi, Yoav Rosenthal, Steven Velkes 265
Werner Zim merli, Parham Sendi 63

6 Lo ca l d e live ry o f a n tib io tics a n d a n tise p tics

Volker Alt 77

7 Diagn o stics
Stphane Corvec, Mara Eugenia Portillo, Josephina A Vossen,
Andrej Trampuz, Peter J Haar 91

XII Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Table of conte nts

Se ct io n 3
Case s
15 .1 Acu te ly in fe cte d tib ia l n a il 19 .2 Im p la n t re m o va lin fe cte d n o n u n io n o f th e tib ia
Jam es F Kellam 283 Jong-Keon Oh 369

15 .2 Acu te ly in fe cte d la te ral m alle o lar fra ctu re 19 .3 Im p la n t re m o va lch ro n ica lly in fe cte d to ta l h ip
A Sam uel Flem ister Jr 289 a rth ro p la st y
Olivier Borens 379
15 .3 Acu te ly in fe cte d p ro xim al h u m e ru s a fte r
so ft-tissu e re p a ir 19 .4 Im p la n t re m o va lch ro n ic in fe ctio n a fte r to ta l kn e e
Matthias A Zumstein 293 a rth ro p la st y
Craig J Della Valle 383
15 .4 In fe cte d tib ial d e la ye d u n io n w ith b ro ke n im p la n ts
Christoph Sommer 297 19 .5 Im p la n t re m o va lin fe cte d to ta l kn e e
re p la ce m e n t
15 .5 Acu te ly in fe cte d p ro xim al fe m o ral fractu re
Stephen L Kates, Christopher J Drinkwater 391
d yn a m ic h ip scre w
Stephen L Kates 309 19 .6 Im p la n t re m o va lin fe cte d to ta l sh o u ld e r
a rth ro p la st y
15 .6 Acu te ly in fe cte d p ro xim al fe m o ral fractu re
Arthur Grzesiak, Alain Farron 4 01
p roxim a l fe m o ral n a il
Michael J Zegg, Christian Kamm erlander 313 19 .7 Im p la n t re m o va lacu te ly in fe cte d to ta l a n kle
a rth ro p la st y
16 .1 Ch ro n ica lly in fe cte d d ista l tib ia l fra ctu re
Lisca Drittenbass, Xavier Crevoisier, Mathieu Assal 4 09
Zhao Xie 319
19 .8 Im p la n t re m o va lch ro n ica lly in fe cte d to ta l
16 .2 Ch ro n ica lly in fe cte d p ro xim al tib ia l fractu re
e lb o w a rth ro p la st y
Zhao Xie 325
Anjan P Kaushik, John C Elfar 415
16 .3 Ch ro n ica lly in fe cte d d ista l fe m o ra l fra ctu re
20 Pe d ia tric o ste o m ye litis
Chang-Wug Oh 331
Theddy Slongo 423
16 .4 Ch ro n ica lly in fe cte d h ip h e m ia rth ro p la st y
20 .1 Oste o m ye litis o f th e d ista l tib ia
Tak-Wing Lau 337
Theddy Slongo 429
16 .5 Ch ro n ica lly in fe cte d d ista l ra d ia l fra ctu re
20 .2 Oste o m ye litis o f th e p roxim al h u m e ru s
Peter JL Jebson, David C Ring, George SM Dyer 345
Theddy Slongo 4 35
17 Acu te o ste o m ye litis o f th e fe m u r
20 .3 Po sto p e ra tive o ste o m ye litis o f th e tib ia
Peter E Ochsner 351
Theddy Slongo 4 43
18 Ch ro n ic o ste o m ye litis o f th e tib ia
20 .4 Oste o m ye litis/ se p tic a rth ritis o f th e p ro xim a l
Peter E Ochsner 357
fe m u r in a to d d le r
19 .1 Im p la n t re m o va lin fe cte d n o n u n io n o f th e Theddy Slongo 4 53
d ista l h u m e ru s
21 Tre a tm e n t o f in fe ctio n w ith lim ite d re so u rce s
Jong-Keon Oh 361
Zhao Xie 4 63

Glo ssa ry 4 69

In d e x 473

XIII
XIV Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
 Se ctio n

Principles 1
Se ct io n 1
Principle s
1 Im p la n t-a s s o cia t e d b io lm
Ko h e i Nish itan i, Kare n d e Me sy Be n tle y, Jo h n L Daiss 3

2 Ho s t im m u n it y
Joh n L Daiss, Ed ward M Schwarz 19

3 Micro b io lo g y
Virgin ia Po st, R Ge o ff Rich ard s, T Fin tan Mo riarty 29

4 Pre ve n t io n o f in t ra o p e ra t ive in fe ct io n
Erlan gga Yu su f, Olivie r Bo re n s 45

5 Sys t e m ic a n t ib io t ics
We rne r Zim m e rli, Parham Se nd i 63

6 Lo ca l d e live r y o f a n t ib io t ics a n d a n t is e p t ics

Vo lke r Alt 77

7 Dia gn o s t ics
St p h an e Co rve c, Mara Eu ge n ia Po rtillo ,
Jose p hin a A Vosse n, And re j Tram p uz, Pe te r J Haar 91
Kohe i Nishitani, Kare n de Me sy Be ntley, John L Daiss
1 Im p la n t-a s s o cia te d b io lm
Ko h e i Nish itan i, Kare n d e Me sy Be n tle y, Jo h n L Daiss
1 Ba s ics
Th e steady in crease in th e u se o total join t replacem en t
(TJR) as th e treatm en t or arth ritis an d oth er severe join t
path ologies attests to its en orm ou s su ccess in im provin g th e
m obility an d qu ality o li e or m illion s o patien ts arou n d
th e w orld [1]. Wh ile th ey are rare, im plan t-associated in ec-
tion s rem ain TJRs m ost eared, devastatin g, an d costly
con sequ en ces [214]. In addition to th e stru ggles o patien ts
com pelled to u n dergo exten sive an tibiotic th erapy, revision
su rgery, an d, in som e cases, th e tragedy o arth rodesis or
am pu tation , th e n an cial costs o im plan t-associated orth o-
pedic in ection s are a m u lti-billion dollar bu rden or h ealth
care providers w orldw ide [2].
Man y species o bacteria can cau se im plan t-associated or-
th opedic in ection s, bu t th e staph ylococci predom in ate,
particu larly th e h u m an com m en sals Staphylococcus aureus
an d Staphylococcus epidermidis. Som e o th e m ajor ch allen ges
w ith im plan t-associated orth opedic in ection s are th at th ey
are h ard to diagn ose, persist again st an tibiotic th erapy, an d
are pron e to recu rren ce. Th ese traits are largely attribu table
to th e li estyle th at path ogen s adopt in th e presen ce o an
orth opedic im plan t. We are accu stom ed to th in kin g th at
bacteria n atu rally grow in su spen sion cu ltu res like th ose
typically u sed in laboratories, bu t m ost, i n ot all, species o
bacteria th rive in a gen etically program m ed, altern ative
li estyle kn ow n as bio lm .
Th is ch apter w ill cover som e o th e m ain eatu res o bio lm s
in clu din g h ow th ey are m ade, h ow th ey in teract w ith th e
h ost im m u n e respon se, an d h ow th ey com plicate detection
an d th erapy. Th e au th ors w ill describe addition al li estyles
o bacteria th at m ay be altern atives or com plem en ts to bio-
lm s, an d w ill brief y en u m erate strategies or overcom in g
bio lm in ection s. Even th ou gh orth opedic in ection s are
cau sed by m an y species o bacteria an d som e bio lm s are
polym icrobial, th e ocu s w ill be on th e m ost ch allen gin g
path ogen s in orth opedic im plan ts, S aureus an d S epidermidis.
In su rgical specim en s, bio lm s are n ot alw ays easy to iden -
ti y. In Fig 1-1 , im ages are presen ted o S aureus bio lm on
th e cem en t o an in ected em oral com pon en t. It appears as
a sh in y, reddish area th at tu rn s black w h en treated w ith
osm iu m tetroxide ( Fig 1-1 b ). Scan n in g electron m icrograph s
o th is an d oth er im plan t-associated bio lm s reveal som e
o th e eatu res depicted in Fig 1-1 c f , in clu din g sin gle an d
clu stered cocci o ten in association w ith con spicu ou s brin
lam en ts.
3
 Se ct io n 1Principle s
1Im plant-associate d
biof lm

a b

c d

e f
Fig 1-1 a f Bio lms obse rve d on orthope dic hardware e xplante d from humans.
This e xample fe ature s an infe cte d fe moral com pone nt re m ove d from a patie nt and xe d in
2.5% glutaralde hyde/ 4.0 % paraformalde hyde for imaging by scanning e le ctron microscopy.
Scanning e le ctron microscopy micrographs of bio lm from this im plant and othe rs (cf ):
a Pale ye llow ce me nt on implants inve rse side displaying re d-brown bio lm .
b Same implant afte r 1.0 % osmium te troxide staining (now black) showing the e xte nt of
the patie nts bio lm cove ring the ce me nt of the implant.
c From the im plant in b , brin cable s supporting the colonization of Sta phylococcus a ure us
indicate d by re d arrows (x 3,0 0 0).
d Colonie s of S a ure us cove ring the ce me nt surface of the implant in b (x 5,0 0 0).
e Cocci (arrows) on the surface from an infe cte d tibial implant (x 3,0 0 0).
f Highe r magni cation from an infe cte d pate llar implant displaying brin which se rve s as a
scaffold for S a ure us cocci (arrows) within bio lm (x 10 ,0 0 0).

4 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Kohe i Nishitani, Kare n de Me sy Be ntley, John L Daiss
2 De fin it io n o f a b io film
Ou r u n derstan din g th at bacteria grow in bio lm s is su rpris-
in gly n ew [15, 16]. In act, th e term bio lm w as rst u sed in
1981 [17], an d it w as n ot u n til th e early 1980s th at th e rst
pu blication s dem on strated th e adh esion an d grow th o bac-
teria on m u ltiple types o m edical devices in clu din g su tu res
[18, 19], pacem akers [20, 21], in dw ellin g cath eters [22], an d
orth opedic im plan ts [23]. We n ow recogn ize th at bacterial
bio lm s are respon sible or at least 65% o bacterial in ec-
tion s in h u m an s in clu din g recu rren t lu n g in ection s an d
diabetic w ou n ds [24]. In addition , w e n ow u n derstan d th at
bacterial bio lm s are th e predom in an t li estyle o bacteria
in th eir n atu ral aqu atic or soil en viron m en ts [24].
Based on h is years o pion eerin g observation s, William
Costerton , Ph D, provided a com pact de n ition o a bio lm :
A stru ctu red com m u n ity o bacterial cells en closed in a
sel -produ ced polym eric m atrix adh eren t to an in ert or
livin g su r ace [25]. Bio lm orm ation is a coordin ated activ-
ity am on g m an y bacterial cells, som etim es even am on g
m u ltiple bacterial species. As previou sly n oted, essen tially
all bacteria can orm bio lm s, an d m an y bio lm s con sist o
m u ltiple bacterial species. Fou n der bio lm - orm in g species
som etim es create th e n ecessary con dition s or th e recru it-
m en t o addition al species so th at bio lm s can develop in to
com plex com m u n ities. Even w ith in a sin gle species bio lm ,
bacteria in discrete zon es, su ch as at th e bottom or th e top
o th e bio lm , w ill m ake ch aracteristic adaptation s givin g
rise to a stru ctu red com m u n ity som etim es equ ated w ith
di eren tiation w ith in th e tissu es o h igh er organ ism s
( Fig 1.2 ) [26].
Th e sel -produ ced m atrix, gen erically re erred to as extracel-
lu lar polym eric su bstan ce (EPS), is com posed o h ydroph ilic,
sparin gly solu ble biopolym ers th at can be produ ced an d
secreted in abu n dan ce creatin g an en viron m en t w h ere bac-
teria can su rvive in th e ace o en viron m en tal stresses like
n u trien t lim itation , w ater f ow , or deh ydration . Th e EPS is
o ten re erred to as a slim e layer becau se o its com bin ation
o adh esive an d coh esive properties. Man y EPS are produ ced
by polym erizin g available su gars su ch as th e 1,3-lin ked
glu cose polym er syn th esized rom extracellu lar su crose in
am iliar den tal bio lm s m ade by Streptococcus mutans. In
S aureus an d S epidermidis th e m ost prom in en t bio lm EPS
is polym erized-N-acetylglu cosam in e (PNAG), alth ou gh th e
relative abu n dan ce o th is w idely u sed polym er varies su b-
stan tially rom strain to strain .
Th e n eed or an in an im ate oreign body in bio lm orm ation
is discu ssed in detail in part 4 o th is ch apter. It h as been
w idely u n derstood th at oreign bodies provide a n idu s or
th e establish m en t o bio lm in ection s dram atically redu cin g
th e bacterial load requ ired or in ection . Bio lm s can also
orm on so t tissu e in th e orm o m icrocolon ies, bu t th e
m ost di cu lt to eradicate bio lm s clin ically are im plan t-
associated.
Com pared to th e relatively u n bridled plan kton ic grow th o
bacteria in rich m edia typical o laboratory experim en ts,
bio lm s are a su rvival m ode th at is relatively costly in term s
o cell division s bu t provide h u ge advan tages in term s o
ability to su rvive h ostile assau lts resu ltin g rom en viron -
m en tal sh i ts or h ost respon ses. Moreover, th e adaptation s
n ecessary or bio ilm orm ation are coordin ated by an
elaborate gen etic program th at in clu des sh i ts in cellu lar
m etabolism an d cooperation am on g bacterial cells.
3 Wh a t is b io film ?
Bio lm s are o ten perceived as static ortresses w h ere
bacteria n d sh elter like people gath erin g in a castle to seek
re u ge rom in vaders. Bio lm s are in deed ortresses providin g
sh elter rom both im m u n ological an d m edical in terven tion s
su ch as n eu troph ils an d an tibiotics. Bu t th is con cept is ar
too lim ited. Bio lm s are also dyn am ic com m u n ities th at
u n dergo th eir ow n li ecycle o attach m en t, accu m u lation /
m atu ration , an d dispersal. In addition , th ey are in cu bators
or at least tw o su bsets o bacteria th at adopt distin ctive
li estyles; each con tribu tes to th e persisten ce o orth opedic
in ection s.
In vitro stu dies o bio lm orm ation h ave revealed a coop-
erative, m u ltistep process typically described as attach m en t,
m atu ration , an d dispersal [2 7 3 1 ]. Sen sin g som e en viron -
m en tal stressor su ch as th e in n ate im m u n e respon se, in di-
vidu al bacterial cells begin to syn th esize h igh in tracellu lar
levels o cyclic di-AMP, w h ich sh i ts gen e expression tow ards
produ cts th at con tribu te to bio lm orm ation [32, 33]. Am on g
th e activated gen es are th ose en codin g m icrobial su r ace
com pon en ts recogn izin g adh esive m atrix m olecu les
(MSCRAMMs), w h ich u n ction as adh esion s, cell w all-as-
sociated, an d secreted m olecu les th at m ediate attach m en t
to h ost protein s likely to be abu n dan t at a w ou n d site su ch
as collagen , brin , vitron ectin , an d bron ectin [34 ]. In vitro
th is is approxim ated by precoatin g plastic su r aces w ith
h u m an plasm a [35].
Follow in g MSCRAMM-m ediated attach m en t, th e adh eren t
staph ylococci divide an d begin th e syn th esis o PNAG, by
th e activation o th e ica operon th at en codes a series o
5
 Se ct io n 1Principle s
1Im plant-associate d
biof lm

Stage 1 Stage 2 Stage 3 Stage 4

Substratum

Implant surface

1a 2a 3a 4a

1b 2b 3b 4b

1c 2c 3c 4c
Fig 1-2 Stage s of bio lm de ve lopm e nt: m ode ls and corre sponding scanning e le ctron microscopy im age s. Bio lm de ve lopm e nt is
typically de scribe d as proce e ding in thre e or four ste ps: attachm e nt, accumulation/ m aturation, and dispe rsal. The se stage s are de picte d
diagramm atically above the corre sponding scanning e le ctron m icroscopy image s of the various bio lm stage s take n from in vitro and in vivo
e xpe rime ntal m ode ls.
1a Exam ple of in vitro attachm e nt of Sta phylococcus a ure us cocci incubate d in a ow cham be r syste m whe re bacte ria are circulate d ove r a
surface of a stainle ss ste e l wire (x 10 ,0 0 0).
1b In vitro: S a ure us cocci using brin to se cure attachm e nt to the wire s surface (x 20 ,0 0 0).
1c In vitro: S a ure us cocci (sim ilar to ( 1b ) labe le d with anti brin antibodie s using imm unogold labe ling and scanning e le ctron m icroscopy
imaging. Note the bright white dots (30 nm gold particle s) on lam e nts con rm ing the ide ntity of brin (x 30 ,0 0 0).
2a c In vitro se rie s of scanning e le ctron m icroscopy im age s of S a ure us form ing large r cluste rs of cocci e ntwine d with brin lam e nts
facilitating a stronge r attachm e nt to the wire s m e tal surface (x 5 ,0 0 0).
3a Mature bio lm uniformly coating a round pin which was re m ove d from a m ouse tibia infe cte d for 14 days by the m e thicillin-se nsitive
S a ure us strain UAMS-1 (x 20 0).
3b Exam ple of the thicke r bio lm form e d by S a ure us UAMS-1 a gr on a transtibial m e tal im plant 14 days postinfe ction (x 15 0).
Sta phylococcus a ure us cocci with de le tion of the a gr ge ne cannot dispe rse so the y accum ulate producing a thicke r bio lm .
3c Highe r magni cation scanning e le ctron m icroscopy im age of ( 3b ) showing the build-up of S a ure us bio lm lacking the a gr ge ne . (Note:
S a ure us UAMS-1 a gr was the gift from the laboratory of Dr Paul Dunm an at the Unive rsity of Roche ste r Me dical Ce nte r, De partm e nt of
Microbiology and Im munology.)
4a Exam ple of S a ure us UAMS-1 le aving be hind e m pty lacunae sugge sting full bio lm m aturation and dispe rsal of the bacte ria (x 5,0 0 0).
4b Exam ple of nondispe rsal by S a ure us UAMS-1 a gr cocci which re m ain within m atrix com pone nts and have fe we r we ll-de ne d lacunae
(x 5 ,0 0 0).
4c Exam ple of lacunae with four S a ure us UAMS-1 cocci e m be dde d in m atrix com pone nts in a bio lm pre se nt on a transtibial im plant afte r
14 days of infe ction (x 3 0 ,0 0 0).

6 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Kohe i Nishitani, Kare n de Me sy Be ntley, John L Daiss
en zym es an d m em bran e protein s th at polym erize, tran sport,
an d partially deacetylate th e grow in g polym er ch ain s th at
can reach len gth s o th ou san ds o sacch aride u n its. To
prom ote PNAG syn th esis, th e bacteria redu ce u n ction s
associated w ith cell division su ch as protein an d DNA syn -
th esis, in crease argin ase, an d u rease m obilize th e requ ired
n itrogen [3 6 , 3 7 ]. In vitro, m an y strain s o S aureus an d S
epidermidis produ ce prim arily PNAG or th eir EPS. Som e
secrete protein s prim arily associated w ith bio ilm s. For
exam ple, S aureus bio lm s in cattle are ch aracterized by th e
abu n dan ce o bio lm -associated protein , polym erized N-
acetylglu cosam in e, an d S epidermidis im plan t-associated
bio lm s h ave h igh levels o accu m u lation -associated protein .
Som e S aureus bio lm s display h igh levels o SasG [3840].
Oth ers secrete extracellu lar DNA an d protein s in a process
th at resem bles apoptosis in eu karyotic cells [4 1 , 4 2 ]. Th e
resu ltin g m atrix lim its access to th e im m u n e system s ele-
m en ts, speci cally n eu troph ils an d m acroph ages, an d m ay
con tribu te to th e en h an ced an tibiotic resistan ce observed
in bio lm s [27 , 2 8 , 3 0 , 3 7].
Man y in vestigators h ave observed m odu lation o bio lm
orm ation in vitro by th e presen ce or absen ce o en dogen ou s
n u cleases, proteases, or glycosidases [43 4 6]. Th e precise
roles o th ese en zym es are n ot yet clear, bu t th eir roles are
n ot strictly degradative. For exam ple, th e accu m u lation -
associated protein expressed in S epidermidis m u st be pro-
teolytically cleaved to con tribu te to bio lm orm ation [47].
Th ere are reports th at secreted proteases are u sed essen tially
as w eapon s, as com petin g species battle or con tested sites
[4850]. Th ese observation s h ave raised th e h ope th at bio lm s
can be readily treated w ith EPS-degradin g en zym es. To date,
th erapeu tic treatm en t w ith degradative en zym es h as n ot
progressed an d th e n otion m ay be sim plistic w h en on e
con siders h ow dyn am ic bio lm s are [51].
As th e bio lm m atu res, th e bacteria con tin u e to divide, an d
local resou rces becom e lim itin g; tw o addition al strategies
or su rvival are in itiated. Som e o th e bacteria u n dergo m u -
tation s th at dram atically redu ce th eir m etabolic requ irem en ts
[5 2 , 5 3 ] or th ey sh i t in to a dorm an t, an tibiotic-resistan t,
persisten t state [54, 55]. Oth ers, in respon se to qu oru m sen s-
in g, m ediated by th e accu m u lation o secreted au toin du cin g
peptides, activate th e m aster con troller gen e, accessory gen e
regu lator (agr), w h ich govern s th e expression o a grou p o
secreted viru len ce actors in clu din g -h em olysin (Hla) an d
th e ph en ol-solu ble m odu lin s [3 0, 37, 5 65 8]. Activation o
agr h as becom e associated w ith th e in itiation o disassem bly
o th e bio lm an d dispersal o bacterial cells to expan d th e
bio lm or popu late n ew su r aces [29, 30, 56, 57]. Th ese stages
are sh ow n sch em atically in Fig 1-2 , togeth er w ith scan n in g
electron m icroscopy im ages depictin g com parable stages
observed rom in vitro an d in vivo bio lm s.
Bio lm s in vivo are w oe u lly u n derch aracterized [59, 60]. As
an in itial e ort, th e au th ors are w orkin g to describe th e
n atu ral h istory o bio lm s th at orm on a f at m etal w ire in
ou r m ou se m odel o im plan t-associated S aureus osteom y-
elitis [61]. In th is m odel, an S aureus con tam in ated, f at stain -
less steel w ire is in serted in to th e tibia o a m ou se an d le t
in place or days to w eeks. Th en it is rem oved an d exam in ed
by scan n in g electron m icroscopy. Th e au th ors in itial objec-
tives h ave been to:
Measu re th e grow th o th e bio lm across th e im plan t
su r ace
Iden ti y th e stru ctu ral eatu res th at develop as th e
bio lm m atu res u sin g scan n in g electron m icroscopy as
th e prim ary readou t
Th e m ain eatu res o th e in vitro m odel described above
m ay apply in vivo, bu t th ere are m an y addition al actors to
con sider su ch as oreign bodies, th e in n ate im m u n e respon se,
h igh levels o plasm a protein s, an d lim ited availability o
essen tial n u trien ts su ch as iron Fe++ [62].
On day 1, th e pin is covered w ith n eu troph ils an d ew
bacteria are observed even th ou gh w e kn ow th at bacteria
are proli eratin g in th e vicin ity o th e pin ( Fig 1-3 a ). Possibly
th ere are so t-tissu e reservoirs o S aureus th at attach to th e
pin su r ace a ter day 1 or clu m ps o brin -agglu tin ated
S aureus th at m an age to establish a n ascen t bio lm [6365]
w h ile en din g o n eu troph ils, or perh aps ph agocytized S
aureus escape rom ph agocytes [66 68 ] to popu late th e pin
su r ace. In an y case, th e presen ce o abu n dan t n eu troph ils
in th e m ou se tibia m akes it u n likely th at th e sim ple adh e-
sion step described in in vitro m odels w ill apply in vivo.
By day 4, th e pin su r ace is dotted w ith clu sters o S aureus
alw ays in association w ith bers th at are 0.020.1 m in
diam eter ( Fig 1-3b ), presu m ably brin resu ltin g rom th e
action o coagu lase or vWbp (see part 4 o th is ch apter).
Th at h ost-derived stru ctu res are com pon en ts o th e in vivo
bio lm s, an d possibly essen tial on es, h as n ot been an tici-
pated in th e in vitro m odels. Sim ilarly, it appears th at 710
m cells, presu m ably n eu troph ils, becom e in corporated in to
th e bio lm . By day 7 ( Fig 1-3c ), clu sters o S aureus are visible
w ith a prom in en t coatin g o an u n ch aracterized m atrix,
possibly th e PNAG o th e in vitro m odels. Fin ally, on day
14 ( Fig 1-3d ), region s w ith a lm com prised o a brou s,
n ely w oven m esh are eviden t an d dim pled w ith depres-
sion s o lacu n ae exactly th e size o S aureus givin g th e
7
 Se ct io n 1Principle s
1Im plant-associate d
biof lm

appearan ce th at th e bacteria h ad resided in th e m esh an d
th en em igrated, perh aps th e resu lt o th e activation o agr,
an d th e expression o dispersal-related protein s like th e
ph en ol-solu ble m odu lin s [2 8 , 3 0 , 5 6 , 5 7 ]. A ter 28 days, S
aureus are seldom observed by scan n in g electron m icroscopy
on th e pin s an d colon y- orm in g u n its are rarely recovered
ollow in g vigorou s extraction o th e pin . How ever, S aureus
RNA can be extracted an d iden ti ed by RNA sequ en cin g,
su ggestin g th e presen ce o persister cells [54, 55].
Th ere are m an y open qu estion s. Even th ou gh th e rem oved
im plan ts rarely h ave bacterial colon y- orm in g u n its a ter
day 28, th e tibiae rem ain cu ltu re positive. I th e im plan t is
n ot th e on ly reservoir or th e in ectin g path ogen , w h ere do
th e bacteria reside? Can th e previou sly popu lated pin be
repopu lated or is th e depopu lated su r ace irreversibly ou led?
Do th e S aureus popu lation s o th e im plan t cycle th rou gh
m u ltiple orm s possibly w ith som e o th e oth er orm s
described in part 5 o th is ch apter?

a b

c d
Fig 1-3 a d Stage s of bio lm de ve lopm e nt obse rve d in the m ouse transtibial im plant m ode l.
Shown are the scanning e le ctron m icroscopy im age s of the tim e course of bio lm m aturation
in the C57BL/ 6 m ouse infe cte d with m e thicillin-se nsitive Sta phylococcus a ure us (SH10 0 0)
[7 5 ]. Sta phylococcus a ure us-inoculate d stainle ss ste e l im plants we re surgically place d in
m ouse tibiae , im plants we re harve ste d at the indicate d tim e point, the n im plants we re
obse rve d by scanning e le ctron m icroscopy.
a At day 1, fuzzy structure s which are pre sum ably from host brin we re obse rve d on the
wire surface , and S a ure us e xiste d as single or sm all cluste rs. Note that host im m une
ce lls are found e lse whe re on the im plant.
b At day 4, S a ure us we re e vide nt as large r cluste rs surrounde d by hone ycom b m atrix.
c At day 7, S a ure us cocci are e m be dde d in bio lm matrix or e xtrace llular polym e ric
substance .
d At day 14, fe w ce lls are obse rve d on the surface , but many shallow bacte rium -size d
de pre ssions are obse rve d. The authors nam e d the se de pre ssions e m pty lacunae and
be lie ve the y re pre se nt site s from which cocci dispe rse d. Afte r day 14, S a ure us bio lm
shows alm ost no m orphological change , indicating that the m aturation of the S a ure us
bio lm is com ple te in 14 days or le ss.

8 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Kohe i Nishitani, Kare n de Me sy Be ntley, John L Daiss
4 In t e ra ct io n b e t w e e n b io film a n d im p la n t
Man y kin ds o oreign bodies are placed in to patien ts. Th ese
in clu de devices in ten ded to last decades su ch as total join t
replacem en ts an d h eart valves, as w ell as tem porary devices
like in traven ou s an d in dw ellin g u rin ary tract cath eters.
Am on g su rgeon s, it is gen erally recogn ized th at oreign bod-
ies sign i can tly in crease th e risk o in ection . Especially in
severely ill or im m u n ocom prom ised patien ts, oreign bodies
are respon sible or 6070% o h ospital-acqu ired in ection s
[69]. Su rgeon s h ave been aw are o th is sin ce th e early 20th
cen tu ry becau se o th e association o abscesses w ith su rgical
stitch es. In th e 1950s, th e risk o oreign bodies w as dra-
m atically dem on strated by arti cial in ection u sin g h u m an
volu n teers [70]. Th is sen sation al stu dy sh ow ed th at on ly 100
cocci w ith a silk su tu re cou ld cau se a su ppu rative in ection ,
w h ereas 100,000 cocci w ere requ ired in th e absen ce o th e
oreign body. In cases in volvin g su tu res, staples, an d in dw ell-
in g cath eters, it is easy to rem ove th e oreign body i in ection
is su spected; h ow ever, diagn osis an d corrective in terven tion
are ar m ore com plicated in deep-seated im plan ts.
Th ere are several rou tes or bacteria to cau se an im plan t-
associated in ection . On e com m on rou te is th e direct local
spread rom exposu re at th e tim e o su rgery. Th ese in ection s
are requ en tly eviden t w ith in 30 days o su rgery. Man y
oth er im plan t-associated in ection s are secon dary to in ection s
o oth er tissu es th at are spread du e to proxim ity, su ch as
in ection s in th e eet o th e patien ts w ith vascu lar in su -
cien cy, or by bacterem ia su ch as h em atogen ou s osteom y-
elitis, wh ich is m ore a com m on cau se o acu te osteom yelitis
in prepu bertal ch ildren an d in vertebral osteom yelitis o th e
elderly [7173].
As described in part 3 o th is ch apter, th e in itial step o th e
im plan t-associated in ection is bacterial adh esion to h ost
protein s adsorbed on th e im plan t su r ace u sin g th eir
MSCRAMMs. On ce bacteria h ave attach ed to th e im plan t
su r ace, th ey can in crease th e cell n u m ber by both cell divi-
sion an d accretion o plan kton ic cells. In act, th e im plan t
su r ace serves as both a secu re an ch orage site th at acilitates
in crease in biom ass, an d it en ables th e attach ed bacteria to
h ave access to oth er h ost actors th at m ay be valu able in
bio lm developm en t. For exam ple, S aureus can polym erize
brin ogen in to poten tially protective brin th rou gh th e
action o coagu lase an d von Willebran d actor-bin din g pro-
tein . Bacteria u se th ese h ost m aterials to bu ild u p th e bio lm
m atrix togeth er w ith bacterial ow n EPS, on th e im plan t
su r ace. Th u s, th e im plan t provides tw o im portan t th in gs
to bacteria: stable an ch orage an d access to m aterials. An
exam ple is presen ted in Fig 1-3 a w h ere cocci are attach ed to
brou s m aterial, presu m ably brin . Bio lm orm ation is
o ten regarded as th e de n in g eatu re o th e ch ron ic stage
o in ection providin g th e path ogen w ith protection rom
h ost im m u n ity an d an tibiotics. However, in h u m an in ection s,
it is n ot clear exactly w h ere to draw th e lin e betw een acu te
an d ch ron ic ph ases o in ection . It probably di ers am on g
bacterial strain s, in itial bacterial in ocu lu m , an d e cien cy
o th e h ost im m u n e respon se. Clin ically, patien ts w h ose
in ection resolves in ew er th an 3 w eeks m ay be can didates
or im plan t reten tion [74]. How ever, in th e au th ors' m u rin e
m odel, S aureus bio lm is in itiated alm ost im m ediately a ter
in ection , an d m atu res w ith in as ew as 714 days [75]. I
bio lm bu ildin g ollow s th e sam e tim e cou rse in h u m an s,
a robu st bio lm w ou ld be expected in as little as 2 w eeks,
th ereby n ecessitatin g im plan t rem oval.
Follow in g th e prin ciple th at preven tion o in ection is m ore
e ective th an treatin g it, m an y in vestigators h ave attem pted
to iden ti y attribu tes th at w ill m ake orth opedic im plan ts
resistan t to in ection . Stain less steel an d titan iu m alloys are
th e m ost com m on m etal m aterials or orth opedic im plan ts.
Man y believe th at th e h igh er cost o titan iu m is o set by it
su perior resistan ce to in ection . Con sequ en tly, th e di er-
en ces betw een stain less steel an d titan iu m im plan ts h ave
been th e su bjects o con siderable in qu iry. Regardin g attach -
m en t, th e in itial step or bio lm orm ation , th e relative
m erits betw een th ese m aterials are still con troversial. Ha et
al ou n d m ore S epidermidis attach m en t to titan iu m alloy
(Ti-6-4) th an to stain less steel (316SS), h ow ever, reported
th e opposite or Mycobacterium tuberculosis [76 ], an d Gracia
et al an d Koseki et al reported n o di eren ce betw een tita-
n iu m an d stain less steel u sin g S epidermidis [77, 78]. In th e
presen t au th ors stu dies, n o di eren ces h ave been observed
in adh esion o S aureus in th e presen ce o h u m an plasm a on
stain less steel or titan iu m K-w ires u sin g a f ow -ch am ber
m odel [79]. Wh ile th e m etal com position o th e im plan t m ay
n ot provide a dem on strable advan tage in preven tin g bacte-
rial adh esion , m u ltiple reports [80, 81] an d a system atic review
[8 2 ] con clu de th at rou gh n ess o th e im plan t su r ace is a
critical actor. In itial adh esion o S aureus to a m odel im plan t
w as less in electropolish ed pu re titan iu m or titan iu m alloy
(Ti-6Al-7Nb) th an to relatively rou gh com m ercial titan iu m
or titan iu m alloy (Ti-6Al-7Nb) [80 ].
Even th ou gh th e su periority o titan iu m m ay n ot be eviden t
rom in itial attach m en t experim en ts, its su perior resistan ce
to in ection h as been con sisten tly observed in vivo. For ex-
am ple, in rabbit stu dies u sin g dyn am ic com pression plates,
th e 35% in ection rate reported or titan iu m alloy w as less
th an h al th e 75% in ection rate o oth erw ise iden tical steel
plates [83]; sim ilar observation s were m ade or in tram edu llary
9
 Se ct io n 1Principle s
1Im plant-associate d
biof lm
n ails w h ere th e in ection rate w as 82% or stain less steel
an d 59% or titan iu m [84]. In a recen t review article, Harris
et al su ggest th at th e discrepan cies betw een in vitro an d in
vivo experim en ts lie in th e act th at so t tissu e adh eres
rm ly to titan iu m im plan t su r aces, w h ile steel im plan ts are
kn ow n to elicit th e orm ation o a brou s capsu le, en closin g
a liqu id- lled void [85]. Alth ou gh th ese stu dies sh ow th e
di eren ce o in ection rates or bacterial bu rden on im plan ts,
direct eviden ce o m atu re bacterial bio lm is n ot clearly de-
scribed an d u rth er stu dies are w arran ted to better u n derstan d
th e di eren ce in bio lm orm ation in di eren t m aterials.
In h u m an stu dies, tw o reports con clu de th at titan iu m is m ore
resistan t to bacterial in ection th an stain less steel. In a
ran dom ized con trolled trial o extern al xation devices or
distal radial ractu re, Pieske et al report a h igh er rate o
rem oval resu ltin g rom severe pin -track in ection , an d o pin
loosen in g in th e stain less steel grou p th an in th e titan iu m
alloy grou p (5% versu s 0% , 10% versu s 5% , respectively)
[86]. In a separate n on ran dom ized con trolled trial stu dy o
tran s xation o toe de orm ities, Clau ss et al reported th at
titan iu m alloy w ires displayed su perior ou tcom es in term s
o recu rren ce o de orm ity an d patien ts pain (39% versu s
13% , 48% versu s 22% , respectively). Fu rth erm ore, in th eir
bio lm an alyses, titan iu m alloy w ires resu lted in h igh er
resistan ce again st bacteria th an stain less steel wires (P < .05)
[87]. Th ese tw o clin ical trials both in volved percu tan eou s
xation ; th e su periority o titan iu m in closed im plan t xa-
tion h as n ot yet been con clu sively dem on strated in h u m an s.
Th ou gh titan iu m im plan ts in crease th e su rgical costs, in th e
su bcu tan eou s xation or h igh risk o in ection cases, su ch
as open ractu re, toe xation , or in com prom ised patien ts,
u sage o titan iu m im plan ts m ay be ben e cial or patien ts.
Exten sive research h as been u n dertaken to preven t bio lm
orm ation by treatin g th e im plan t su r ace. E orts to preven t
th e in itial bacterial attach m en t to th e im plan t h ave in clu ded
polish in g th e m etal su r ace [88 ], coatin g it w ith TiO2 [89, 90],
an d addin g su r actan ts [91 ]. Staph ylococci h ave th eir ow n
protein s th at prom ote aggregation or m odi y h ost protein s
su ch as brin ogen or bron ectin to prom ote in itial adh esion
an d su bsequ en t bio lm orm ation . Attem pts to cou n ter th e
attach m en t o bacterial aggregates h ave in clu ded coatin g
im plan ts w ith h u m an seru m albu m in [9 2 ], polyeth ylen e
glycol (PEG) [80], h ydroxyapatite [93], an d ch itosan [94] h ave
sh ow n som e ben e t in vitro. Coatin g im plan ts w ith silver,
a kn own an tim icrobial, decreases th e attach m en t o bacteria
[9 5, 96 ], as does coatin g w ith iodin e [97]. An tibiotic-laden
m etallic im plan ts h ave been stu died sin ce th e 1950s an d
h ave sh ow n som e prom ise, h ow ever, th ey are n ot available
com m ercially at presen t.
10
Alth ou gh an im plan t su r ace or a bon y sequ estru m is a
avorable site or bacterial bio lm orm ation , livin g bon e
su r ace is n ot. On e attribu te o th e livin g bon e su r ace is th e
presen ce o com m u n ities o n u m erou s osteoblasts an d
osteoclasts on th e en dosteu m , an d periosteal cells an d
broblasts on periosteu m . Several in vestigators h ave at-
tem pted to prom ote th e selective grow th o h ost-cell popu -
lation s on th e im plan t su r ace. Coatin g th e su r ace w ith
speci c titan iu m [98], or poly-L-lysin e-gra ted-polyeth ylen e
glycol (PLLg-PEG) acilitated th e adh esion o h ost cells to
th e im plan t su r ace an d in h ibited th e attach m en t o bacteria
[85, 98]. Th ou gh th ese cells do n ot directly com bat bacteria,
in creasin g th ese h ost cells on th e im plan t su r ace leads to
early so t-tissu e coverage an d/ or bon e m in eralization on
th e im plan t su r ace an d resu lts in less bio lm orm ation .
5 Pa t h o ge n e s is o f im p la n t-a s s o cia t e d in fe ct io n s
Th e prim ary an d earliest h ost respon se to bacteria is an acu te
in f am m atory reaction , led by th e rapid recru itm en t o n eu -
troph ils in to th e in ection site. Neu troph ils are th e rst lin e
o h ost de en se again st bacteria an d patien ts w h o h ave
gen etic or acqu ired n eu troph il in su cien cies are pron e to
developin g requ en t an d li e-th reaten in g in ection s [99 ]. On
th e su r ace o an in ected im plan t, n eu troph ils are observed
in th e very early stages o th e in ection ( Fig 1-3a ). Activation
o com plem en t protein s opson izes bacteria acilitatin g th eir
in gestion by ph agocytes in clu din g th e in ltratin g n eu troph ils
an d residen t m acroph ages. Cytokin es, su ch as in terleu kin -1
(IL-1), IL-6, an d tu m or n ecrosis actor (TNF) are released
an d act as ch em otactic actors an d activators o ph agocytic
cells. Th ese in itial respon ders o th e h ost de en se again st
bacteria are elem en ts o in n ate im m u n ity w h ich u se an cien t
m ech an ism s evolu tion arily con served rom in sects [10 0 ]. In
in n ate im m u n ity, all im m u n ocom peten t cells recogn ize
oreign an d dan gerou s stru ctu res ch aracteristic o bacteria
via toll-like receptors (TLRs) [1 0 1 ]. By u sin g a variety o
TLRs, n eu troph ils recogn ize bacterial lipopolysacch arides,
peptidoglycan s, bacterial DNA, an d oth er path ogen -associ-
ated m olecu lar pattern s: or exam ple, TLR9 bin ds bacterial
DNA an d TLR4 recogn izes lipopolysacch arides [102].
In th e acu te in f am m atory ph ase, in creases w ill be observed
in several serological tests, n otably w h ite blood-cell cou n t,
C-reactive protein , eryth rocyte sedim en tation rate, an d
procalciton in . Locally, th e ou r classic sign s o in f am m ation :
pain , h eat, redn ess, an d sw ellin g, are u su ally observed du e
to th e local vasodilation an d ch em otaxis o in f am m atory
cells, prim arily n eu troph ils. In m an y cases, orth opedic im -
plan t in ection s can cau se osteom yelitis. In bon e, osteoblasts
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Kohe i Nishitani, Kare n de Me sy Be ntley, John L Daiss
also express TLRs 2, 4, an d 9, an d respon d to bacterial stru c-
tu res to produ ce an tim icrobial peptides, ch em okin es an d
in f am m atory cytokin es, an d receptor activator o n u clear
actor kappa-B ligan d (RANKL) [103, 104]. By th e in f u en ce
o RANKL an d oth er proin f am m atory cytokin es, osteoclast
precu rsors m atu re in to osteoclasts. Osteoclasts also secrete
cytokin es an d ch em okin es, w h ich in du ce ch em otaxis o ad-
dition al precu rsors an d prom ote osteoclastogen esis [105, 106].
By th ese am pli yin g cascades, osteoclasts participate in para-
crin e an d au tocrin e regu lation o m assive bon e resorption
in osteom yelitis. Bacterial toxin s th em selves also h ave a
stron g stim u latory e ect on osteoclasts by directly a ectin g
osteoclast gen eration , su rvival, an d activation ; an d by in di-
rectly prom otin g th e produ ction o RANKL an d oth er osteo-
clastogen ic actors [107, 108]. Moreover, bio lm can directly
regu late variou s h ost cells to in du ce RANKL an d cau se bon e
resorption [109]. Th is bon e resorption cau ses th e loosen in g
o th e im plan t, w h ich is o ten observed as a radiolu cen t lin e
in plain x-rays or com pu ted tom ograph ic im ages, an d im plan t
loosen in g is an oth er cau se o th e pain in th e in ected patien t.
In classic osteom yelitis, th e local osteolysis is ollow ed by
th e orm ation o th e in volu cru m , w h ich is a rin g o n ew
reactive bon e su rrou n din g th e in ection site an d ragm en ts
o dead bon e called sequ estra. In im plan t-associated in ection
cases, th ou gh it is n ot as typical as classic sequ estru m an d
in volu cru m , bon e resorption an d reactive bon e orm ation
are observed. Alth ou gh n ecrotic bon e is orm ed as early as
10 days postin ection , plain x-rays are u n able to detect
sequ estru m or sclerotic bon e or m an y w eeks [110].
Ch ron ic in ection s can last years or even decades an d are
requ en tly resistan t to m edical or su rgical in terven tion . Th e
ch ron ic stage gen erally produ ces m ore in ection -related bon e
dam age an d requ ires m ore aggressive in terven tion . Exten -
sive an tibiotic th erapy in com bin ation w ith irrigation an d
debridem en t is som etim es su cien t or th e elim in ation o
m an y in ectin g m icroorgan ism s. How ever, on ce S aureus
h as been con rm ed by cu ltu re, th e stan dard o care or TJR
patien ts is tw o-stage exch an ge arth roplasty w h ich eatu res
rem oval o th e prim ary im plan t an d debridem en t ollow ed
by w eeks or m on th s o an tibiotic th erapy [9, 74]. Rem arkably,
30% o patien ts n ever ach ieve th e criteria or reim plan ta-
tion . Wh ile reim plan tation is attem pted in abou t 70% o
in ected patien ts, as m an y as 1020% becom e rein ected.
Th u s, th e com bin ed ailu re rate or S aureus-in ected TJR
approach es 50% .
Som e rein ection s resu lt rom di eren t m icroorgan ism s, bu t
m ost recu rren t in ection s are w ith th e sam e strain as th e
in itial in ection [1 1 1 ]. Wh at is th e ph ysical basis or th is
rem arkable persisten ce? Mu ltiple citation s attest th at th ese
S aureus in ection s can persist or over 60 years [112, 113]. In
addition to bio lm s, w e are becom in g aw are o still oth er
li estyles o staph ylococci. Th ese in clu de su rvival m odes
th at h ave been observed in clin ical specim en s an d an im al
m odels:
Microcolon ies
Abscesses
Adoption o an in tracellu lar li estyle
Opportu n istic su rvival in protected n ich es in th e h ost
Each o th ese m ech an ism s m ay con tribu te to th e persisten ce
o S aureus in ection s, an d it is possible th at in dividu al strain s
o S aureus can u se m ore th an on e o th ese strategies in
ch ron ic in ection .
Microcolon ies h ave been observed in m an y settin gs w h ere
th ey are associated w ith recu rren t in ection s. Microcolon ies
are n ot w ell de n ed, bu t appear to be so t-tissu e-associated
patch es o bio lm th at are clin ically associated with recu rren t
so t-tissu e in ection s [114, 115], an d th ey h ave been observed
in a m ou se m odel o ch ron ic osteom yelitis [1 1 6 ]. Little is
kn ow n abou t th eir orm ation or stability. Wh ile w e h ave
n ot observed m icrocolon ies in ou r osteom yelitis m odels,
th ey are in clu ded in th is discu ssion prim arily as an oth er
poten tial reservoir o ch ron ic in ection th at h as been docu -
m en ted in laboratory an d clin ical settin gs.
Staphylococcus aureus abscesses m an ipu late th e h osts in n ate
im m u n e respon se to create sh ort-term sh elter th at can be
reservoirs or recu rren ce [117]. Th e orm ation o abscesses
in clu des zon es de n ed by a perim eter o brin deposits
su rrou n din g an in ection . How ever, S aureus h as developed
ways to m an ipu late th e n orm al h ost respon se to its advan tage,
possibly con tribu tin g to prolon ged exten sion o ch ron ic in -
ection . Usin g a m ou se m odel o bacterem ia th at leads to
abscess orm ation in m u ltiple organ s, Sch n eew in d et al h ave
described a ou r-step process o abscess developm en t an d
regen eration [117].
Th e li e cycle o an abscess is in th e order o a m on th , an d
th ere is little eviden ce th at th e im m u n e respon se elicited
by th e in itial in ection h as an y protective valu e again st
rein ection [1 1 8 , 1 1 9 ]. Con sequ en tly, su ccessive cycles o
abscess orm ation cou ld be a veh icle or lon g-lastin g ch ron ic
in ection s.
Fu rth er in vestigation s in th e au th ors laboratory h ave ex-
am in ed th e im pact o an tibodies selected or poten tial im -
m u n e in ter eren ce w ith th e progress or persisten ce o
S aureus in ection s in th e m odel o im plan t-associated
11
 Se ct io n 1Principle s
1Im plant-associate d
biof lm
osteom yelitis. Im m u n oglobu lin G an tibodies th at block th e
en zym atic activities o th e bi u n ction al cell-w all m odi yin g
en zym e au tolysin redu ced th e n u m ber o abscesses th at
orm ed in th e bon e m arrow , an d en able m acroph age pen -
etration o th e in terior o th e abscess [79].
Gen erally con sidered an extracellu lar path ogen , S aureus
m ay persist as sm all-colon y varian ts (SCV) in side h ost cells
[120]. Th e possibility o an in tracellu lar li estyle or S aureus
is based on n u m erou s observation s o in tern alization o
S aureus by n on pro ession al ph agocytes su ch as keratin ocytes,
epith elial cells, an d osteoblasts [1 2 1 1 2 4 ]. In vitro, su ch
in tern alization requ en tly leads to death or apoptosis o th e
h ost cell [12 5 , 1 26 ], bu t in som e in stan ces th e h ost cells are
stably in ected w ith SCVs o S aureus [12 7]. Sm all-colon y
varian ts are distin gu ish ed by th e presen ce o m u tation s in
m en adion e or h em in u ptake, elevated expression o Fn BpA,
decreased expression o agr an d Hla an d distin ctive colon ies
in vitro th at are n on lytic (n o Hla), n on colored (n o staph y-
loxan th in ), an d sm all. Th e h ypoth esis is th at th ese in tracel-
lu lar SCVs are an oth er poten tial sou rce o lon g-lived persisten t
in ection s an d th at th ese associated ch an ges are adaptation s
to th e in tracellu lar li estyle. In terest in SCVs h as been
en h an ced by clin ical observation s o SCVs cu ltu red rom
ch ron ic osteom yelitis patien ts [116, 128].
Oth ers h ave reported th e iden ti cation o S aureus in osteo-
blasts [116], bu t th ere is n o in dication so ar th at su ch in ec-
tion s are regu larly observed. Th e au th ors h ave exam in ed
n u m erou s ch ron ic in ection s u sin g a tran stibial pin m odel
an d h ave so ar n ot observed in tracellu lar S aureus in livin g
osteoblasts or an y oth er residen t cell type.
Staphylococcus aureus can su rvive in protected n ich es in th e
h ost. As th e acu te in ection progresses, bon e n ear th e in ection
site is lysed in a region rin ged by n ew bon e orm ation , th e
in volu cru m , th at su rrou n ds an d isolates th e path ogen an d
12
dead bon e ragm en ts called sequ estra. Both in volu cra an d
sequ estra are ch aracteristic o osteom yelitis in h u m an s. In
prin ciple, sequ estra can serve as a reservoir or prolon ged
su rvival o S aureus [112]. In act, in recen t exam in ation s o
sequ estra by tran sm ission electron m icroscopy, th e au th ors
h ave observed th e presen ce o S aureus in sm all ssu res in
th e sequ estru m , w h ich th ey call m icrocracks. Th e abu n dan ce
o cells w ith cell division septa in dicates th at th e bacteria
are alive an d dividin g. In a related an d u n expected observa-
tion , th e au th ors iden ti ied th e presen ce o S aureus in
can alicu li, th e 0.20.5 m ch an n els th at serve as con du its
or com m u n ication betw een th e su r ace o th e bon e an d
osteocytes em bedded in cortical bon e ( Fig 1-4 ). It is probable
th at S aureus in can alicu li can su rvive in de n itely by dis-
solvin g bon e locally to gain access to collagen , an d also by
con su m in g rem n an ts o th e residen t osteocytes.
Th e su ccess o th ese su rvival m odes or S aureus an d th e
requ en cy o ch ron ic or recu rren t in ection s are au gm en ted
by th e im poten t n atu re o th e h u m an adaptive im m u n e
respon se to n atu ral in ection s. Each o th e ch ron ic in ection
m odes described above provides a h aven or S aureus or a
n ite tim e be ore it n eeds to be re orm ed or con verted to
an oth er m ode. Bio lm s, an d possibly m icrocolon ies, appear
to be particu larly dyn am ic, proceedin g th rou gh th e en tire
cycle o adh eren ce, m atu ration , an d dispersal in w eeks an d
possibly days. Likew ise, abscesses tu rn over w ith in a m on th
or so. I SCVs in osteoblasts are to be in de n itely stable,
th ey n eed to n d n ew h ost cells w h en th eir residen t cell
tu rn s over. Fin ally, S aureus in sequ estra w ill u ltim ately
con su m e th e local n u trien t su pply an d n eed som e m ech a-
n ism or escape an d rein ection . In deed, th e n eed o th ese
proposed reservoirs o lon g-term in ection to tu rn over h as
attracted th e atten tion o developers o an tibiotics h opin g
to iden ti y valu able n ew targets or in terven tion [129136].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Kohe i Nishitani, Kare n de Me sy Be ntley, John L Daiss

6 Co n clu s io n

Th e clin ical ch allen ges su rgeon s ace in im plan t-associ-

a su r ace.
MC
N in cu bators spaw n in g ast-grow in g, viru len t bacteria
MC
N
N Im plan ts in clu din g TJRs, plates, n ails, screw s, an d
b o th e h ost.
OC
Co rt ica l b o n e m a t rix
c
Fig 1-4 a c Sta phylococcus a ure us invade s both surgically produce d
m icrocracks and bone canaliculi.
a Sta phylococcus a ure us in bone (arrows). Large cluste r of de ad
ne utrophils ( inside ye llow bars).
b Sta phylococcus a ure us invade s (arrows) m icrocracks (MC)
cause d by surgical drilling into bone . Note se ve ral de ad
ne utrophils (N) adjace nt to the m icrocrack.
c Sta phylococcus a ure us invasion (arrow) into cortical bone and
canaliculi adjace nt to an oste ocyte (OC) [13 7 ].
ated in ection s are du e to th e grow th o bacteria in
bio lm s.
Even th ou gh th e con cept o bio lm s is n ew to h u m an s,
bio lm s are an cien t li estyles or essen tially all bacteria.
In vitro, bio lm s are th e produ cts rom gen etically
program m ed steps an d cooperative beh avior am on g
bacteria th at con stru ct a m atrix o sel -m ade, extra-
cellu lar polym eric su bstan ces on a livin g or n on livin g
In vivo, bio lm s are m osaic m atrices com prisin g both
bacterial an d h ost com pon en ts.
Bacteria ben e t rom bio lm s by acqu irin g resistan ce
to an tibiotics an d to h ost im m u n e respon ses.
Bio lm s are n ot static ortresses. Th ey are dyn am ic
th at disperse to popu late n ew su r aces, as w ell as
slow -grow in g an tibiotic-resistan t persister cells.
su tu res are excellen t oreign bodies th at can dram ati-
cally avor th e local grow th o bacteria at th e expen se
Th e im m u n e respon se is n ot very e ective again st
S aureus bio lm in ection s becau se o its capabilities o
m odu latin g th e h ost im m u n e respon se.
Th e m an agem en t o ch ron ic S aureus in ection s m ay be
m ade m ore di cu lt becau se S aureus h as addition al
li estyle option s th at m ay also be protective an d h ow
th ey in teract w ith bio lm s is u n kn ow n .
Treatm en t o im plan t su r aces an d in terven tion in
every step in th e bio lm li estyle are areas o active
in qu iry or th erapeu tic in terven tion .

13
 Se ct io n 1Principle s
1Im plant-associate d
biof lm
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17
 Se ct io n 1Principle s
1Im plant-associate d
biof lm

18 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

John L Daiss, Edward M Schwarz
2 Ho s t im m u n it y
Jo h n L Daiss, Ed ward M Sch warz
1 Ba s ics
1.1 Ro le o f t h e im m u n e s ys t e m
Bacteria, both com m en sals an d path ogen s, obtain ood an d
sh elter rom h u m an s. On e o th e u n dam en tal di eren ces
betw een prokaryotic an d eu karyotic organ ism s is th e tim e
it takes to m ake a n ew cell. Mam m alian cells divide in abou t
24 h ou rs com pared to bacteria w h ich can divide in as little
as 20 m in u tes in a n u trien t-rich en viron m en t. In th e tim e
a m am m alian cell divides on ce, a sin gle bacteriu m cou ld go
th rou gh 72 gen eration s an d produ ce abou t 10 30 progen y.
O cou rse th is is u n likely, bu t th e poin t is th at in order to
provide a robu st de en se, ou r im m u n e system h as to e -
cien tly destroy su ch rapidly grow in g in vaders. Th e h u m an
im m u n e system is design ed to totally degrade in vadin g
m icroorgan ism s by com bin in g:
Solu ble com pon en ts in th e blood th at recogn ize an d
lyse th e m icrobe (h u m oral im m u n ity)
Microbe-eatin g cells th at carry degradative m ach in ery
w ith in th em (cellu lar im m u n ity)
Th u s, u n dam en tal con cepts to u n derstan d h ost im m u n ity
in th is brie ch apter are:
Th e m ain elem en ts o th e im m u n e system
Th eir m ech an ism s or recogn ition an d action again st
bacteria
1.2 Lim it a t io n s o f t h is ch a p t e r
We lim it ou r con sideration s o th e h ost im m u n e respon se
to bacterial path ogen s, th e prim ary cau ses o orth opedic
in ection s. Alth ou gh sim ilar ru les apply, im m u n ity again st
u n gi, viru ses, Protista, an d w orm s are n ot speci ically
addressed. Assu m in g th at orth opedic in ection s gen erally
resu lt rom a sign i can t breach o th e skin or m u cosa, ou r
discu ssion w ill be lim ited to th e system ic im m u n e respon se;
th e m u cosal im m u n e respon se w ill n ot be addressed.
1.3 Tw o s ys t e m s t h a t in t e ra ct
Th e m am m alian im m u n e respon se h as com e to be perceived
as tw o distin ct an d in teractin g system s [1 ]. Historically,
in vestigators an d ph ysician s h ave th ou gh t in term s o h u -
m oral im m u n ity an d cellu lar im m u n ity, a distin ction rst
m ade in th e 1890s by scien tists in clu din g Em il von Beh rin g,
Ju les Bordet, an d Pau l Eh rlich , wh o discovered th e protective
powers o sera rom in ected an im als [2]. Th ey also discovered
th e presen ce o h eat-stable, in ection -in du cible actors in
th e sera (an tibodies), an d o a secon d h eat-labile, n on in du c-
ible actor th at w orked w ith th e an tibodies to kill bacteria
(com plem en t). Con siderin g th at scien tists w en t on to save
m illion s o ch ildren rom a cru el death rom diph th eria
u sin g seru m alon e, on e can respect th eir perception th at
h u m oral im m u n ity w as m ost im portan t. At th e sam e tim e,
Ilya Metch n iko discovered th at im m u n ity cou ld be m edi-
ated by ph agocytic cells th at en gu l ed an d killed bacteria
[3]. Logically, h e con clu ded th at im m u n ity w as m ediated by
th ese specialized cells an d called th em ph agocytes. Wh ile
cellu lar an d h u m oral im m u n ity w ere in itially perceived to
be som eh ow in opposition , it h as been clear or over a cen -
tu ry th at h u m oral an d cellu lar elem en ts o im m u n ity w ork
togeth er to preven t an d cu re in ection [3].
A m ore con tem porary distin ction is based on th e iden ti cation
o tw o distin ct evolu tion ary strategies or de en se again st
bacterial in ection s: th e in n ate im m u n e respon se an d th e
adaptive im m u n e respon se. Th e tw o system s are com ple-
m en tary an d in teractive ( Fig 2-1 ). Th e in n ate im m u n e system
is alw ays at th e ready an d can be en gaged w ith in m in u tes
o a n ascen t in ection . In con trast, th e adaptive im m u n e
system takes w eeks to becom e u lly en gaged an d provides
en h an ced de en se in th e even t o re-exposu re to th e sam e
path ogen .
19
 Se ct io n 1Principle s
2Host
immunity

Invading bacteria

PAMPs

Innate Adaptive

Tissues Lymph nodes

Th1
Circulating neutrophils

Naive T-cell Th2

Macrophage
Th17

Treg
Neutrophil
Immature dendritic cell Mature dendritic cell Antibody
antigen collecting antigen presenting

B-cell

Mast cell Plasma cell

C3 MBP

C3b MBP
Opsonized bacteria

C3b MBP

Lysis by complement Ingestion by phagocytes

Fig 2-1 Sche m atic de piction of the m ain e le m e nts of the innate and adaptive im m une syste m s. Invading bacte ria produce PAMPs which
e licit the se cre tion of cytokine s and vasodilators from tissue -re side nt macrophage s and m ast ce lls and re cruitm e nt of ne utrophils from the
circulation. Bacte ria coate d with com ple m e nt or MBP are inge ste d by phagocyte s or lyse d by com ple m e nt. Im mature de ndritic ce lls colle ct
antige ns from the bacte ria and m ature into antige n-pre se nting ce lls that m igrate to the lym ph node s whe re the y e ngage and activate antige n-
spe ci c T and B ce lls. Activate d T ce lls se cre te cytokine s that furthe r activate m acrophage s ( Th1), ne utrophils ( Th17), and B ce lls ( Th2);
re gulatory T ce lls ( Tre g) produce im m unosuppre ssive m ole cule s. Activate d B ce lls m ature into antibody-producing plasma ce lls or m e m ory B
ce lls. Antibody binding to bacte ria furthe r prom ote s com ple m e nt activation and phagocytosis by macrophage s and ne utrophils.
Abbre viations: PAMPs, pathoge n-associate d m ole cular patte rns; MBP, mannose -binding prote in.

20 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

John L Daiss, Edward M Schwarz
2 Th e in n a t e im m u n e s ys t e m : co n s e r ve d ,
d is p e rs e d , ra p id , a t t h e re a d y
Th e evolu tion o m u lticellu lar organ ism s requ ired th e
developm en t o m ech an ism s to de en d again st con stan t attack
by path ogen ic m icrobes seekin g ood an d sh elter. As a resu lt,
all in vertebrate an d vertebrate an im als rom ru it f ies to
m an sh are a rem arkably con served array o cellu lar an d
h u m oral com pon en ts, w h ich collectively are re erred to as
in n ate im m u n ity. Im portan tly, m an y o th ese com pon en ts
are n ot speci c or im m u n e de en se, bu t serve addition al
vital u n ction s. For exam ple, th e exoskeleton , or skin an d
m u cosae, con stitu te a di cu lt-to-pen etrate barrier or m ost
path ogen s. Beyon d ph ysical barriers, w e are en dow ed w ith
cells th at produ ce an tibacterial agen ts in clu din g m icrobici-
dal peptides [4, 5] an d lipids [6]. Sh ou ld bacteria breach th e
prim ary skin barrier by pu n ctu re, in sect bite, or w ou n d,
th ey w ill im m ediately be aced w ith tw o elem en ts o th e
im m u n e system : a h u m oral com pon en t called com plem en t
an d a cellu lar com pon en t th at are m acroph ages dispersed
th rou gh ou t th e con n ective tissu es [7]. In m am m als, com ple-
m en t is th e prim ary h u m oral lytic agen t o th e in n ate im m u n e
system . It com prises a am ily o abu n dan t seru m protein s
th at prom ote de en sive action by:
1. Iden ti yin g in vadin g bacteria
2. Recru itin g an d activatin g im m u n e cells like m acro-
ph ages an d n eu troph ils
3. Sel -assem blin g in to a lytic pore th at directly kills
certain gram -n egative bacteria
In th e absen ce o an tibodies (see part 3 o th is ch apter) on e
o th e com plem en t protein s, C3, h as th e special property o
con tain in g an in tern al th ioester bon d th at is spon tan eou sly
broken at a low rate gen eratin g a h igh ly reactive en zym e
(C3b), wh ich can react w ith an y cell su r ace. On n orm al h ost
tissu es th e reactive C3b is rapidly in activated, bu t m ost
bacteria can n ot in activate C3b, w h ich can covalen tly attach
itsel to th e cell w all an d in itiate a sel -am pli yin g series o
proteolytic even ts th at set th ree processes in m otion . Firstly,
proteolytic produ cts called an aph ylatoxin s are released an d
act as ch em otactic sign als or n earby ph agocytes. Secon dly,
th e ph agocytes bear cell su r ace receptors w h ich bin d to th e
m icrobe-bou n d C3b, prom otin g in gestion an d in tern al deg-
radation . Fin ally, activated C3b in itiates a ch ain reaction
w ith addition al com plem en t com pon en ts, an d u ltim ately
produ ces a m acrom olecu lar assem bly th at creates a pore in
th e cell m em bran es o certain types o bacteria leadin g to
osm otic lysis. Th is process o com plem en t activation is called
th e altern ative path w ay, an d it is on e o th e th ree w ays th at
th e lytic pow er o th is protein system can be targeted again st
path ogen ic bacteria.
Th e cellu lar com pon en ts in m ost tissu es are lon g-lived,
residen t cells o th e im m u n e system called m acroph ages,
m ast cells, an d den dritic cells. As th e n am e im plies, m acro-
ph ages are big eaters: ph agocytes th at in tern alize an d
degrade bacteria an d oth er organ ic m aterials. Macroph ages
are presen t m ostly in con n ective tissu es w h ere th ey serve
m u ltiple roles. Firstly, th ey clear h ost cells th at n orm ally
tu rn over by apoptosis [8], so th ey h ave a h ou sekeepin g u n c-
tion separate rom th eir role in im m u n ity. Secon dly, th ey
recogn ize an d kill in vadin g bacteria th rou gh receptors on
th eir cell m em bran es th at are speci c or su r aces laden w ith
th e produ cts o activated com plem en t. Bacteria coated w ith
ph agocytosis-prom otin g protein s like com plem en t are said
to be opson ized, based on a Greek w ord loosely tran s-
lated as to prepare or din in g. Th irdly, th ey act as sen tin els,
an d secrete bioch em ical sign als called cytokin es, su ch as
tu m or n ecrosis actor (TNF) an d in terleu kin s-1, -6, an d -8
(IL-1, -6, -8). Th ese secreted produ cts am pli y both local
an d system ic elem en ts o th e in n ate im m u n e respon se
resu ltin g in in f am m ation (h eat an d sw ellin g) at th e site o
in ection .
In f am m atory cytokin es also in du ce cell-su r ace ch an ges in
th e local en doth elia, w h ich are recogn ized by blood-born e
n eu troph ils. Th e n eu troph ils literally m igrate th rou gh th e
en doth eliu m (extravasation ) an d ollow th e bioch em ical
trail con sistin g o cytokin es, an aph ylatoxin s, an d bacterial
debris to th e site o in ection (ch em otaxis). Alon g w ith
m acroph ages, n eu troph ils destroy th e in vadin g bacteria.
Macroph ages are in itially presen t as relatively ew, lon g-lived,
m etabolically active ph agocytes already position ed in th e
tissu es. In con trast, n eu troph ils are recru ited in great n u m bers
rom th e bloodstream , w h ere th ey are th e m ost abu n dan t
w h ite blood cells [9]. Distin gu ish ed by th eir relatively sm all
size, distin ctive h eteroch rom atic, m u ltilobed n u clei, an d
gran u lar cytoplasm , n eu troph ils are m obile veh icles con tain -
in g presyn th esized an tibacterial agen ts in clu din g sm all
an tim icrobial peptides, degradative en zym es, an d gen erators
o toxic reactive oxygen species. Th ey can deliver th eir
toxic payload eith er by degran u lation (releasin g th eir an ti-
m icrobial con ten ts to th e im m ediate en viron m en t) or th ey
can in gest th e bacteria an d kill th em by degradin g th em
in tern ally. Addition ally, th ese cells can also kill bacteria in
a su icidal process called NETosis, in w h ich th ey com bin e
th eir DNA w ith lysosom al protein s to catch an d destroy
m icrobes in n eu troph il extracellu lar traps [10, 11].
Mast cells con tain abu n dan t h istam in e-rich gran u les th at
are released u pon stim u lation by, am on g oth er th in gs, C5a,
on e o th e an aph ylatoxin s n oted above. Histam in e release
leads to local vasodilation acceleratin g th e in f u x o n eu troph ils,
21
 Se ct io n 1Principle s
2Host
immunity
rapidly m an i ested as eryth em a an d sw ellin g. Th is rapid
cascade leads to system ic respon ses th at direct addition al
lytic activity to th e in ection site, an d attem pt to restrict
bacterial proli eration an d spread. For exam ple, w ith in a
ew h ou rs, secreted sign als, n otably tu m or n ecrosis actor-
(TNF- ) an d in terleu kin -6 (IL-6), stim u late th e produ ction
o acu te-ph ase protein s in th e liver, in clu din g opson in s su ch
as th e com plem en t protein C3, an d C-reactive protein (CRP),
an d protein s su ch as erritin , h epcidin , an d ceru loplasm in
th at lim it th e availability o m etal ion s, particu larly Fe ++
w h ich is essen tial or bacterial grow th . A secon d exam ple
o a system ic respon se is th e elevation o tem peratu re.
In terleu kin s-6 an d TNF- , am on g oth er sign alin g m olecu les,
stim u late th e secretion o prostaglan din E2 (PGE2) by cells
in th e h ypoth alam u s w h ich govern s body tem peratu re.
Elevated tem peratu re slow s bacterial division rates an d en -
h an ces som e im m u n e respon ses [7 ].
Sin ce th e in n ate im m u n e respon se is m ostly derived rom
preexistin g resou rces th at can be applied im m ediately to
gen erate a robu st local an d system ic respon se, it is essen tial
th at rigorou s con trols lim it th e in itiation an d exten t o th e
respon se to preven t seriou s tissu e dam age or death (eg,
toxic sh ock syn drom e). For th e m ost part, th is con trol lies
w ith evolu tion arily con served receptors in m acroph ages
an d den dritic cells, re erred to as pattern -recogn ition receptors
(PRR), w h ich speci cally recogn ize path ogen -associated
m olecu lar pattern s (PAMPs) an d bioch em ical stru ctu res th at
are u n iqu e to path ogen s an d absen t in m etazoan h osts. Th ere
are th ree classes o PRRs:
Toll-like receptors (TLR)
NOD-like receptors (NLR)
Lectin -like receptors
Discovered in itially in Drosophila, TLRs are cell m em bran e-
associated PRRs th at recogn ize PAMPs rom m an y poten tial
path ogen s in clu din g bacteria, viru ses, an d u n gi in th e ex-
tracellu lar en viron m en t [12]. Bacteria-speci c PAMPs in clu de
peptidoglycan an d ph en ol-solu ble m odu lin s (TLR2); lipo-
polysacch aride (LPS; TLR4); lipoteich oic acid (LTA; TLR6);
an d CpG-con tain in g DNA (TLR9). Toll-like receptors do n ot
directly drive ph agocytosis by m acroph ages or n eu troph ils;
th ey prom ote secretion o cytokin es an d in terleu kin s th at
activate oth er im m u n e cells. NOD-like receptors are in tra-
cellu lar receptors th at stim u late th e secretion o im m u n e
activators w h en bacteria h ave su ccess u lly in vaded h ost cells.
It is w orth n otin g th at on e o th e receptors in th is am ily
(NOD2/ CARD15) h as been iden ti ed as a su sceptibility gen e
in Croh n s disease [1 3 , 1 4 ] h igh ligh tin g th e dan gers o a
dysregu lated in n ate im m u n e system .
22
Fin ally, a solu ble receptor m an n ose-bin din g protein (MBP,
also called m an n an -bin din g lectin ) th at bin ds su gars re-
qu en tly presen t on bacterial cell w alls bu t n ot on h u m an
cells, activates com plem en t w h ich coats th e bacterial su r ace
w ith opson izin g com plem en t produ cts [15].
3 Ad a p t ive im m u n it y: ce n t ra lize d , s lo w ,
cu s t o m -m a d e
3 .1 Th e ch a lle n ge
In n ate im m u n ity h as evolved to m an age con stan t exposu re
to th e m ost abu n dan t path ogen s. Th is approach to h ost
de en se h as m ajor lim itation s or vertebrates th at h ave lon g
li e span s, in clu din g th e m ean s to de en d again st a n ew
path ogen ic toxin s, strain s, or species th at n ever existed
be ore. To ach ieve th is, th e adaptive im m u n e respon se h as
developed th e ability to recogn ize an y m olecu lar stru ctu re,
w h ile m ain tain in g sel -toleran ce to preven t severe au toim -
m u n ity th at Pau l Eh rlich origin ally described as h orror
au totoxicu s. As a resu lt, th is secon d recogn ition system adds
pow er u l m olecu les an d cell types to th e h osts de en ses,
an d syn ergizes w ith th e in n ate im m u n e system to en h an ce
th e activity o both com plem en t an d ph agocytes to recogn ize
an d destroy extracellu lar bacteria. In addition , th e adaptive
im m u n e system adds tw o n ew capabilities to h ost im m u n ity:
Th e ability to iden ti y an d destroy h ost cells w ith
path ogen s in side o th em
Im m u n ological m em ory, th e ability to m ain tain a
popu lation o lon g-lived cells ready to respon d to a
secon d ch allen ge by a previou s in vader
An tibodies are th e m ost w ell-kn ow n aspect o adaptive
im m u n ity. Each an tibody is a protein m olecu le th at bin ds
w ith exqu isite speci city to a discrete m olecu lar stru ctu re
in trodu ced by an in vadin g bacteriu m . Th e bacterial protein
or carboh ydrate stru ctu re targeted by th e an tibody is called
its an tigen . Upon an tigen bin din g, an tibodies activate com -
plem en t (com plem en t xation ) an d prom ote th e in gestion
o bacteria by ph agocytes (opson ization ). Th is du al n atu re
o an tibodies w as discovered over a cen tu ry ago by Pau l
Eh rlich w h o called th em Zwischenkrper or con n ectin g bod-
ies [1 6]. Th e m odu lar stru ctu re o th e an tibody m olecu le
reveals h ow th e con n ectin g u n ction is ach ieved.
Th e m ost w idely stu died type o an tibodies is called im m u -
n oglobu lin G (IgG). Th ey sh are a com m on stru ctu re com -
posed o tw o types o polypeptide ch ain s; 25 kDa ligh t ch ain s
an d 50 kDa h eavy ch ain s ( Fig 2 -2 ). Each h eavy ch ain pairs
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
John L Daiss, Edward M Schwarz
w ith on e ligh t ch ain an d th e h eavy ch ain s are paired to yield
a ou r-polypeptide, 150 kDa m olecu le th at assem bles in a
Y-sh ape am iliar in m ost im ages o IgG. Th e arm s o th e Y
are called th e Fab ( ragm en t w ith an tigen -bin din g activity);
th e stem o th e Y is called th e Fc ( ragm en t th at crystallizes
or is con stan t), an d th e sh ort segm en t betw een th em is called
th e h in ge region .
HV regions
VH
VL
CH1
Fab
CL
Hinge
CH2
Fc
CH3
Fig 2-2 The anatom y of an im m unoglobulin G antibody m ole cule .
Antibodie s are bivale nt 15 0 kDa prote ins consisting of two ide ntical
25 kDa light chains and two ide ntical 5 0 kDa he avy chains that
asse m ble into a Y-shape d m ole cule . Each light chain is folde d into
two 12.5 kDa globular dom ains de signate d the VL (variable re gion
of the light chain) and the CL (constant re gion of the light chain).
Sim ilarly, the he avy chain is folde d into four 12 .5 kDa globular
dom ains: VH, CH1, CH 2 , and CH 3; CH1 and CH 2 are se parate d by
a short e xte nde d se gm e nt calle d the hinge re gion. The two he avy
chains are associate d through the hinge re gion and the CH 2 and CH 3
dom ains constitute the Fc (fragm e nt that crystallize s or is constant)
re gion of the m ole cule that m e diate s inte raction with com ple m e nt
and phagocyte s. Each light chain is paire d with one he avy chain
through inte ractions be twe e n the CL and the CH1 dom ains and the
VH and VL dom ains. Toge the r the se form the Fab re gion which is
the antigen-binding part of the antibody with the antigen-spe ci c Hv
re gions pre sente d at the ends of the arms of the Y.
Th e ligh t ch ain con sists o tw o 12.5 kDa globu lar dom ain s:
on e n ear th e en d o th e top o th e Y called th e VL or variable
region o th e ligh t ch ain an d on e n ear th e n eck o th e Y (ie,
th e h in ge) called th e CL or con stan t region o th e ligh t ch ain .
Th e CL is iden tical in sequ en ce or all th e an tibodies o th e
sam e class an d does n ot ch an ge w ith bin din g speci city. Th e
sequ en ce o th e VL varies am on g an tibodies w ith di eren t
an tigen -bin din g speci cities. A close look at th e ligh t-ch ain
am in o acid sequ en ces o a diverse selection o an tibodies
reveals th at th ere are n u m erou s sequ en ce di eren ces be-
tw een an y tw o VL dom ain s an d th at th ese di eren ces are
clu stered in th ree segm en ts called h ypervariable (Hv) region s.
Th e Hv region s old in th e n ish ed m olecu le at th e ou term ost
en d o th e Fab arm creatin g part o a u n iqu e an tigen -spe-
ci c bin din g site. Th e h eavy ch ain is con stru cted alon g
sim ilar lin es; th e VH dom ain n earest to th e ou term ost en d
o th e Fab arm con tain s th e th ree Hv region s th at old so
th at th ey orm a con tin u ou s su r ace w ith th e Hv region s o
th e VL, m akin g a com posite su r ace th at m axim izes sequ en ce
diversity at th e tips o th e Fab arm s. Th e h eavy ch ain h as
th ree con stan t region s design ated CH1, CH 2, an d CH 3. Th e
CH1 com bin es w ith th e CL com pletin g th e Fab; th e h in ge,
CH 2, an d CH 3 dom ain s o tw o h eavy ch ain s align w ith each
oth er to orm th e Fc.
An tibodies are cu stom -m ade, sh ape recogn ition m olecu les
th at can be selected to speci cally bin d to alm ost an y an tigen
stru ctu ral elem en t o an in vadin g path ogen , alth ou gh protein s
an d carboh ydrates predom in ate. B-cells produ ce th e an ti-
bodies an d each B-cell is com m itted to th e produ ction o a
sin gle type o an tibody m olecu le, a key distin ction rom th e
in n ate system w h ere each m acroph age or n eu troph il ex-
presses m an y or all o th e in n ate recogn ition m olecu les in -
clu din g TLR an d receptors or m u ltiple-com plem en t produ cts.
Th e diversity o th e Hv region s, an d con sequ en tly th e ran ge
o stru ctu res th at can be recogn ized, is based on tw o asci-
n atin g gen etic m ech an ism s. First, VH an d VL dom ain s are
created by th e com bin atorial assem bly o m u ltiple discrete
gen etic segm en ts rom an exten sive repertoire o gen om i-
cally-en coded V-region ragm en ts du rin g B-cell on togen y
in th e bon e m arrow . Each B cell is com m itted to a sin gle
assem bled VH / VL pair, w h ich u n ction s as th e B-cell receptor
(BCR). Im portan tly, B cells th at assem ble a BCR th at recogn ize
h ost actors in th e bon e m arrow are killed o in a process
call clon al deletion . Th en u rth er BCR speci city can be
ach ieved via VH an d VL targeted som atic h yperm u tation in
th e V-region gen es u n der th e in f u en ce o oth er adaptive
system cells called T cells. Th is process, called a n ity m at-
u ration , leads to th e creation o an tibodies th at bin d m ore
tigh tly to th eir an tigen s.
23
 Se ct io n 1Principle s
2Host
immunity
3 .2 An t ib o d ie s e n h a n ce t h e a ct ivit y o f in n a t e
im m u n e e ffe ct o rs
Th e tw o m ain e ectors o bactericidal activity o th e in n ate
im m u n e system are com plem en t an d ph agocytes. An tibodies
au gm en t th e im pact o each by in creasin g th e n u m ber
path ogen -speci c an tigen s th e im m u n e system can target
an d th ey ach ieve th is by cooperation w ith an tibody-speci c
adapter m olecu les. We h ave already described th e activation
o com plem en t by th e altern ative an d m an n ose path w ays;
an tibodies are th e th ird w ay to ocu s th e activity o com ple-
m en t on to a path ogen . Ju st as MBP is an adapter m olecu le
th at con n ects com plem en t to m an n ose-rich stru ctu res on
bacteria, so an tibodies recru it com plem en t th rou gh in terac-
tion w ith solu ble com plem en t actors, th e rst o w h ich is
called C1. C1 bin ds to th e Fc region s o IgG w h en th ey are
presen t in a closely-packed array as m igh t be ou n d w h en
m an y are IgG m olecu les bou n d to th e su r ace o a bacteriu m
by th eir Fab arm s. Ju st as Eh rlich s Zwischenkrper m odel
predicts, th e Fab provides th e speci city wh ile th e Fc con n ects
to th e e ector m ech an ism s.
Th e in teraction o IgG, bacteria, an d ph agocytes is sim ilar
except th at th e adapter m olecu le is a receptor protein in th e
plasm a m em bran e o th e ph agocyte. As in th e case or com -
plem en t C1, th e receptor is speci c or th e Fc part o IgG,
so it is called th e Fc-receptor. En cou n terin g IgG m olecu les
den sely arrayed on a bacterial su r ace a m acroph age or
n eu troph il w ill in gest an d destroy th e bacteriu m .
3 .3 Fo r ce r t a in b a ct e ria , a n t ib o d ie s a lo n e ca n p ro t e ct
a ga in s t in fe ct io n
Man y bacteria secrete toxin s th at prom ote in ection by dam -
agin g h ost cells an d cau sin g severe path ology. An tibodies
can be elicited th at n eu tralize th ese toxin s, redu ce th e tissu e
dam age an d allow th e im m u n e system to m ore readily
de eat th e in vadin g path ogen . Well-kn ow n cases in clu de
pertu ssis, tetan u s, an d diph th eria [2].
3 .4 Th e re a re m u lt ip le t yp e s o r cla s s e s o f a n t ib o d ie s
In addition to IgG an tibodies, th ere are m u ltiple oth er types
o an tibodies th at di er in th e con stan t region s an d m ediate
oth er u n ction s. Im m u n oglobu lin M is th e rst an tibody
m ade in respon se to in ection an d a poten t activator o
com plem en t; IgA an tibodies are m ade prim arily in respon se
to m u cosal in ection s; IgE an tibodies are associated w ith
w orm in ection s an d allergy.
24
3 .5 Th e in n a t e a n d a d a p t ive im m u n e s ys t e m s a re
co n n e ct e d b y s p e cia lize d a n t ige n -p re s e n t in g
ce lls ca lle d d e n d rit ic ce lls
Like m ast cells an d m acroph ages, im m atu re den dritic cells
are preposition ed in th e tissu es w h ere th ey m on itor an d
collect th e array o an tigen s presen t in th at vicin ity. Upon
stim u lation by th e presen ce o path ogen s, th ey tran s orm
in to an tigen -presen tin g m atu re den dritic cells an d m igrate
to lym ph n odes or oth er secon dary lym ph oid tissu es w h ere
th ey in teract w ith T cells. Depen din g on th e path ogen an d
th e con stellation o an tigen ic sign als th e den dritic cell h as
processed, n ave T cells w ill di eren tiate in to on e o sev-
eral types: Th 1 cells th at stim u late m acroph age activity, Th 2
cells th at stim u late B-cell activity, Th 17 cells th at prom ote
n eu troph il an d osteoclast activity, or regu latory T cells (Treg)
th at lim it poten tial im m u n ological over-reaction .
3 .6 Ce lls o f t h e a d a p t ive im m u n e s ys t e m in t e ra ct
b y b o t h s e cre t e d s ign a ls a n d d ire ct ce ll-t o -ce ll
co n t a ct
Un like th e in n ate im m u n e system , cells o th e adaptive im -
m u n e system com m u n icate th rou gh a am ily o cell-su r ace
receptors th at in corporate an d display peptide ragm en ts o
th e path ogen . Th is w ill n ot be developed u rth er h ere except
to say th at each B cell an d each T cell expresses on ly on e
an tigen receptor, w h ich or B cells is a cell su r ace-bou n d
an tibody (BCR), an d or T cells is th e T-cell receptor (TCR).
Th ere are m illion s o T-cell an d B-cell clon es available, bu t
on ly a tin y raction o each type are likely to react w ith an y
given an tigen du rin g an im m u n e respon se, in part du e to
th e processes o n egative selection an d periph eral toleran ce
th at elim in ate au toreactive lym ph ocytes by in du cin g an ergy
an d apoptosis. Un itin g an tigen -presen tin g den dritic cells
w ith an tigen -speci c T cells an d B cells requ ires a place
w h ere in ten sive sortin g can occu r u n til produ ctive com bin a-
tion s are iden ti ed, resu ltin g in th e produ ction o m ore
an tigen -speci c cells an d an tigen -speci c an tibodies. Lym ph
n odes are th e places w h ere th is sortin g an d selective grow th
o activated B cells an d T cells occu rs.
3 .7 Ad a p t ive im m u n e s ys t e m h a s m e m o r y
Du rin g an active in ection , path ogen -speci c B cells an d T
cells th at h ave con n ected in th e lym ph n ode proli erate
rapidly. Som e o th e dau gh ter cells becom e im m ediately
en gaged in th e on goin g im m u n e respon se. For exam ple,
m ost B cells becom e th e prodigiou s an d sh ort-lived produ c-
ers o an tibody m olecu les called plasm a cells. How ever, a
su bpopu lation en ters th e circu lation an d travels to oth er
lym ph oid tissu es an d th e bon e m arrow , w h ere th ey becom e
lon g-lived m em ory B cells available or activation u pon
rein ection .
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
John L Daiss, Edward M Schwarz

3 .8 Ha rm o n izin g t h e d is co ve rie s o f Eh rlich a n d 4 Im p a ire d im m u n it y

Me t ch n iko ff
View ed th rou gh th e len s o th is ch apter, w e can see th at
Metch n iko , th e advocate o cellu lar im m u n ology, an d
Eh rlich , th e advocate o h u m oral im m u n ology, each m ade
cru cially im portan t observation s abou t h ow im m u n ity w orks
in h u m an s. In act, th ey sh ared th e Nobel Prize or Medicin e
in 1908 [3]. It is also clear th at each w as lookin g at a very
lim ited aspect o th e w h ole system . Eh rlich w as ocu sed on
an tibodies prim arily in a disease, diph th eria, w h ere m ost o
th e path ology w as cau sed by a secreted toxin . Th e rem oval
o th e bacteria th at secreted th e toxin w as in visible to h im ,
an d w as probably per orm ed by m acroph ages an d n eu tro-
ph ils. Metch n iko h ad discovered th e role o ph agocytes in
m an y species in clu din g w ater f eas an d star sh . He w as
observin g in n ate im m u n ity in action , an d u n aw are o th e
opson in s th at gu ided th e in gestion o in vadin g bacteria.
Over a cen tu ry later, w e n ow h ave th e privilege o u n der-
stan din g h ow elem en ts o im m u n ity, cellu lar an d h u m oral,
in n ate an d adaptive, w ork togeth er. A su m m ary o th e in -
n ate an d adaptive im m u n e system s is presen ted in Ta b le 2 -1 .
Protection rom in ection by th e im m u n e system requ ires
th at each elem en t w orks properly an d in teracts e cien tly
w ith th e oth er elem en ts. Th ere are at least th ree classes o
actors th at im pair th e im m u n e system leadin g to en h an ced
risk or bacterial in ection s.
First, som e patien ts h ave prim ary im m u n ode cien cies in
m ajor elem en ts o th e im m u n e system [1]. Th e m ost popu -
larly kn ow n cases are th e bu bble boys w h o h ave X-lin ked
severe com bin ed im m u n ode cien cy resu ltin g rom m u ta-
tion s in a gen e essen tial or T-cell developm en t. Lackin g T
cells, th ey h ave aberran t B-cell u n ction an d essen tially n o
adaptive im m u n ity. How ever, de cien cies in th e cen tral
in n ate im m u n e com pon en ts, com plem en t, an d ph agocytes
also h ave severe con sequ en ces. For exam ple, m u tation s in
C3 or in th e protein s th at lead to its activation like MBL an d
C1 lead to in creased risk o bacterial in ection s. Likew ise,
ph agocyte de cien cies, n otably severe con gen ital n eu tro-
pen ia w h ich cau ses dram atic redu ction s in th e abu n dan ce

Attribute Innate Adaptive

Response time Minutes to hours Days to weeks
Distribution vs centralization Distributed, already positioned, with circulating cells in support Centralized, circulating cells interact in lymph nodes and spleen
Range o specif cities Narrow Vast
Principle structures recognized PAMPs: mannans, cell-wall components, DNA Peptidoglycan, proteins, capsule polysaccharides
Time o synthesis Preexisting Custom-made
Major cell types Myeloid cells: Lymphocytes:
Macrophages B cells
Neutrophils Th1 cells
Mast cells Th2 cells
Dendritic cells Th17 cells
Treg cells
Major cytokines TNF- IL-2
IL-1 IL-5
IL-6 IL-6
IL-8 IL-4
IFN- IL-10
IFN-
Major receptors Complement receptors TLR T-cell receptors
Mannose-binding protein Membrane Ig (B-cell receptor)
MHC I and II
FcR
Memory No Yes, memory cells
Receptor distribution Each effector cell possesses many receptors from a limited set Each B cell or Tcell expresses one antigen receptor; but a vast
repertoire is expressed by the billions of cells
E ectors Phagocytes Phagocytes
Complement Complement
Natural killer cells Cytotoxic Tcells

Ta b le 2 -1 Sum m ary of the attribute s of the innate and adaptive im m une syste m s.
Abbre viations: PAMPs, pathoge n-associate d m ole cular patte rns; TNF- , tum or ne crosis factor- ; IL, inte rle ukin; IFN- , inte rfe ron- ; MHC,
m ajor histocom patibility com ple x; FcR, Fc re ce ptor; Tre g, re gulatory T ce lls.

25
 Se ct io n 1Principle s
2Host
immunity
o n eu troph ils, or ch ron ic gran u lom atou s disease w h ich
ren ders ph agocytosis-com peten t m acroph ages an d n eu troph ils
in capable o killin g in tern alized bacteria, an d leaves patien ts
vu ln erable to requ en t an d severe bacterial in ection s.
Secon dary or acqu ired im m u n ode cien cies are am iliar
prim arily becau se o th e prevalen ce o acqu ired im m u n o-
de cien cy syn drom e an d h u m an im m u n ode cien cy viru s,
w h ich elim in ates essen tial T-cell popu lation s. How ever, less
dram atic bu t m ore com m on con dition s, speci cally type II
diabetes m ellitu s an d agin g, m ay be m ore im portan t actors
in clin ical practice. Th e precise m ech an ism s h ave n ot been
u lly determ in ed, bu t th ese patien ts su er in creased re-
qu en cy an d persisten ce o bacterial in ection s [17, 18].
A th ird category o im m u n e im pairm en t is th at cau sed by
in ectin g path ogen s. Man y bacteria secrete produ cts th at
directly alter th e im m u n e system . Staphylococcus aureus, a
m ajor cau se o orth opedic in ection s, is a com pellin g ex-
am ple. It h as developed an im pressive array o secreted ac-
tors th at in ter ere w ith essen tially every m ajor elem en t o
both in n ate an d adaptive im m u n ity. It secretes protein s th at
alter or in h ibit th e u n ction s o T cells (secreted exotoxin
A) [19], B cells (protein A) [20 ], n eu troph ils ( -h em olysin
[21, 22], CHIPS), m acroph ages (aden osin e syn th ase) [23], an d
com plem en t (SCIN). In m an y patien ts, th e im m u n e respon se
is m in im ally e ective du e to th ese im m u n osu ppressive
actors [24, 25 ]. Even th ou gh an tibodies are m ade again st
th ese bacterial protein s, th ey are n ot gen erally protective,
an d prior in ection requ en tly does n ot protect again st
rein ection even by th e sam e strain o S aureus [26, 27].
26
5 Ou t lo o k
Th e im m en se grow th o total join t replacem en t an d oth er
orth opedic im plan t su rgeries, an d its rem arkable ou tcom e
in m ost patien ts, represen t som e o m edicin es greatest
su ccess stories. How ever, th ere is alw ays a dark side, an d
or total join t replacem en t an d ractu re xation su rgery th at
h as been im plan t-associated in ection , prim arily w ith S au-
reus. Th e con ven tion al clin ical in terven tion h as been th e
elaborate an d exten sive u se o an tibiotics, w h ich requ en tly
ails, n ecessitatin g su rgical in terven tion an d som etim es
explan tation . Wh ile th ese in ection s are in requ en t, th ey
are seriou s an d expen sive [2 83 1]. Th u s, n ew approach es
are bein g sou gh t to redu ce th e requ en cy o in ection s an d
to provide clin ician s w ith better th erapeu tic option s w h en
th ey occu r.
On e approach h as been th e developm en t o su r ace treat-
m en ts th at w ill preven t th e adh esion o bacteria th ereby
redu cin g th e oreign body e ect [32] an d preven tin g th e
establish m en t o n ascen t in ection s [3335]. Th ese in clu de
toxic m etals like silver, protein s th at preven t bacterial adh e-
sion , an d im m obilized an tibiotics. Oth ers in clu de in jectable,
biodegradable h ydrogels th at can serve as lon g-term depots
or an tibiotics.
With th e risin g requ en cy o an tibiotic-resistan t m icroorgan -
ism s, m an y observers oresee a com in g era o path ogen -
speci c th erapeu tics an d associated diagn ostics [36]. Som e
target th e bacteria directly, su ch as lytic en zym es or bacte-
rioph age [3739]. Th ere are at least th ree classes o im m u -
n ological reagen ts th at are cu rren tly u n der in vestigation .
Th e rst is passive vaccin ation w ith IgG an tibodies selected
to directly ocu s com plem en t an d ph agocytes again st th e
bacteriu m . Several attem pts to ach ieve th is h ave ailed, an d
oth ers rem ain u n der developm en t [26, 4044]. Th e secon d
is an alogou s to th e u se o an tibodies again st diph th eria
toxin , ie, passive im m u n ization to redu ce th e im pact o
secreted toxin s an d en able th e im m u n e system to operate
m ore e ectively [2 1 , 2 2 ]. A th ird approach is to bypass
bacteriu m -derived im m u n e in h ibitors by providin g th e
cytokin es th at th e bacteria h ave evolved to su ppress [45 ].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
John L Daiss, Edward M Schwarz

6 Co n clu s io n

Bacterial in ection rem ain s a seriou s problem in orth opedics,

particu larly in association w ith im plan ts. Ou r im m u n e
system is gen erally adequ ate to iden ti y an d elim in ate m ost
bacterial in ection s th rou gh in n ate an d adaptive processes
described brief y above an d su m m arized in Fig 2 -1 an d
Ta b le 2-1 . How ever, som e patien ts h ave an elevated risk or
in ection , in clu din g th ose w ith h ereditary im m u n ological
disorders, an d, m ore com m on ly, th ose w ith type II diabetes
m ellitu s. Con ron ted w ith m icroorgan ism s th at h ave evolved
w ays to th w art m an y o th e elem en ts o th e in n ate or
adaptive im m u n e respon ses, som e patien ts can n ot overcom e
early in ection s an d progress to ch ron ic, som etim es li e-
th reaten in g in ection s th at requ ire exten sive th erapy. Im -
m u n ological in terven tion s gu re prom in en tly in th e spectru m
o th erapeu tic con cepts u n der developm en t or th ese
ch allen gin g in ection s.

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Ste phe n L Kate s, Olivie r Bore ns
Virginia Post, R Ge off Richards, T Fintan Moriarty

3 Micro b io lo gy
Virgin ia Post, R Ge o ff Rich ards, T Fin tan Mo riarty

1 Ba s ics prim arily du e to th e act th at m an y o th e m icroorgan ism s

Th e con rm ed presen ce o viable bacteria in an y in traop-
erative tissu e specim en is a critical poin t in th e treatm en t
o orth opedic patien ts. Cu ltu re-positive biopsies de n e th e
cou rse o treatm en t or th e patien t, an d it is th ere ore
vitally im portan t th at cu ltu re resu lts are available rapidly
an d are reliable [1, 2]. In adverten t con tam in ation o tissu e
biopsies m ay divert th e treatm en t path an d com prom ise
patien t care. On e o th e m ost cru cial issu es in th e m icro-
biological diagn osis o a bon e in ection , th ere ore, is to di -
eren tiate in ectin g path ogen s rom in n ocu ou s con tam in an ts.
By de n ition , in ection is described as th e in vasion an d
m u ltiplication o bacteria w ith in a tissu e, w h ile con tam in a-
tion is th e presen ce o bacteria in a sam ple bu t does n ot
im ply an in vasive in ection . Th e m ost com m on sou rces o
con tam in ation o in traoperative sam ples are rom u n ltered
air, skin f akes, or u n sterile sam ple h an dlin g. Un ortu n ately,
th e m icrobiological laboratory is u n able to di eren tiate w ith
an y certain ty con tam in an ts rom in ectin g bacteria. Th is is
com m on ly associated w ith bon e in ection s are also readily
cu ltu red rom person n el an d m aterials in th e operatin g room
an d th e laboratory.
Th e bacteria m ost com m on ly isolated rom bon e an d join t
in ection s are sh ow n in Fig 3 -1 . Th ese bacterial species are
n ot con sidered pro ession al path ogen s, an d all are regu larly
presen t in th e n orm al h u m an m icrobiom e or u biqu itou s
in h abitan ts o th e en viron m en t. Th e n atu ral h abitat o
bacteria varies depen din g u pon th e species, alth ou gh m an y
o th e m ost com m on m icroorgan ism s, su ch as Staphylococcus
aureus an d Staphylococcus epidermidis, are com m on ly presen t
on h u m an skin . In act, S epidermidis is u biqu itou sly presen t
on th e h u m an skin an d resides th ere com m en sally, ie, w ith -
ou t an y in ter eren ce in th e n orm al h ealth y skin . Approxi-
m ately 30% o th e h u m an popu lation also h arbor S aureus,
w h ich is th e m ost prom in en t an d possibly m ost viru len t
path ogen en cou n tered in bon e an d join t in ection s [1 ].

1%
2%
3%
5% Micro o rga n is m Fre q u e n c y (%)
30% Sta phylococcus a ure us 30
10%
Polym icrobial 27
Coagulase -ne gative staphylococci 22
Gram -ne gative bacilli 10
Anae robe s 5
22%
Ente rococci 3
Unknown 2
27% Stre ptococci 1

Fig 3-1 Pre vale nce of bacte rial pathoge ns in bone and joint infe ctions [1].

29
 Se ct io n 1Principle s
3Microbiology
Staphylococcus aureus m ay also reside com m en sally on h u m an
skin bu t is also capable o cau sin g skin in ection s in oth erw ise
h ealth y in dividu als. Oth er poten tial path ogen s are also com -
m on ly presen t on or in th e h u m an body: Propionibacterium
acnes colon izes th e h u m an skin (particu larly m oist areas su ch
as th e arm pit); en terococci (Enterococcus aecalis an d Enterococ-
cus aecium) an d Escherichia coli are n orm ally ou n d in th e
gastroin testin al tract; an d n u m erou s streptococci m ay be
ou n d in th e h u m an oral cavity an d respiratory tract. Man y
oth er poten tial path ogen s m ay be ou n d in th e en viron m en t,
in clu din g Pseudomonas aeruginosa, w h ich is com m on ly ou n d
in water system s an d m an y o th e m ore rarely en cou n tered
species su ch as Acinetobacter baumannii, m ycobacteria, an d
Candida albicans.
Each o th ese bacterial species poses a u n iqu e com bin ation
o ch allen ges to treatin g ph ysician s in clu din g th e clin ical
presen tation o th e disease, th e bacteriological cu ltu re con -
dition s requ ired to recover th e respon sible path ogen s, an d
th e an tibiotics th at m ay be e ective again st th em . Th e aim
o th is ch apter is to provide an overview o th e m ost critical
eatu res th at de n e th e m ost com m on path ogen s in bon e
in ection .
30
1.1 Viru le n ce a n d p a t h o ge n icit y
In th e term in ology o bacterial in ection , path ogen icity is a
term th at describes th e ability o a m icroorgan ism to cau se
a disease in a h ost organ ism . Th e m ech an ism s or tools u sed
by a path ogen to do so are term ed its viru len ce actors. Th e
reason on ly a lim ited n u m ber o bacterial species regu larly
appear in bon e in ection patien ts is du e to th e act th at on ly
th ose bacteria possess su cien t viru len ce actors en ablin g
th em to evade on e or m ore o th e h ost de en ses to establish
an in ection . Th e m ost sign i can t viru len ce actors in clu de
bio lm orm ation , adh esion to h ost-tissu e com pon en ts in
a speci c (ie, n on ran dom ) m an n er an d in activation o h ost
de en se m olecu les su ch as an tibodies, or h ost de en se cells
su ch as polym orph on u clear n eu troph ils. In th e absen ce o
a skin breach , in ection o th e u n derlyin g tissu e by oppor-
tu n istic path ogen s th at lack poten t viru len ce actors is
u n likely. How ever, low -viru len ce m icroorgan ism s m ay be
a orded assistan ce in establish in g an in ection by th e su rgical
in cision an d placem en t o an im plan t as occu rs in trau m a
an d orth opedic su rgery. Man y bacteria retain th e ability to
adh ere an d attach to th e su r ace o im plan ted m aterials,
w h ich provides a su r ace to w h ich th e bacteria attach or
adh ere. On ce adh eren t on th e im plan ted device, m an y
bacteria w ill rapidly orm a com plex bio lm ( Fig 3 -2 ) an d
also adapt th eir m etabolism an d gen e expression pro le to
take advan tage o th e protection o ered by th is in an im ate
object in th e h ost. In th is w ay, low -viru len ce m icroorgan -
ism s m ay gain en try to th e deep tissu es an d su ccess u lly
establish in ection .
Fig 3-2 Bacte rial bio lm form e d by Sta phylococcus a ure us on the
surface of a titanium substrate . In this m ode of growth, bacte ria are
m uch more re sistant to antibiotics and host de fe nse s.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Virginia Post, R Ge off Richards, T Fintan Moriarty

Th e clin ical presen tation o an y particu lar patien t w ith a
bon e in ection m ay ran ge rom an acu te in ection ch aracter-
ized by sw ellin g, pu s orm ation , an d pain at on e en d o th e
spectru m , to a su btle, su bclin ical, an d pain - ree in ection at
th e oth er en d. Th e variability in clin ical presen tation resu lts
rom a com bin ation o th e h ost respon se an d th e viru len ce
o th e in ectin g bacteria. Th e exten t to w h ich bacterial
viru len ce m ay in f u en ce th e presen tation o an in ection is
probably best illu strated by com parin g S aureus an d S epi-
dermidis. On a gen etic basis, th ese tw o species belon g to th e
sam e gen u s an d con siderable gen etic in orm ation is sh ared
betw een th e species. How ever, S aureus h as acqu ired a sig-
n i can t am ou n t o addition al gen etic in orm ation th at h as
en dow ed it w ith m an y m ore viru len ce actors, in clu din g
on e o th e de n itive tests or S aureus: coagu lase ( Fig 3 -3 ).
Th e ability to coagu late h u m an plasm a, or exam ple, is
believed to en able th e bacteria to avoid ph agocytosis at th e
cen ter o th e plasm a clot. Su ch viru len ce actors allow
S aureus to cau se, in m ost cases, an acu te in ection . In con trast,
S epidermidis h as n ot acqu ired th ese viru len ce actors an d is
typically u n able to in du ce an aggressive acu te in ection .
Th e prim ary reason S epidermidis is capable o cau sin g an
in ection is prim arily du e to bio lm orm ation . Du e to its
ability to rapidly orm den se bio lm s an d its u biqu itou s
presen ce on h u m an skin , S epidermidis h as em erged as an
im portan t opportu n istic path ogen in device-related bon e
in ection s. Oth er th an bio lm orm ation , S epidermidis does
n ot retain m an y viru len ce actors, w h ich accou n ts or th e
typical appearan ce o a su bacu te or ch ron ic in ection , lackin g
in th e aggressive eatu res associated w ith S aureus in ection .
A sim ilar n din g h as been observed or P acnes, an oth er
u biqu itou s skin colon izer, w h ich can cau se bon e destru ction
an d retain s som e viru len ce actors, bu t w h ich typically cau ses
a localized in ection w ith ou t an aggressive system ic respon se.
Th ese gen eralization s o ten h old tru e, alth ou gh exception s
to th e ru les are o cou rse possible. Deviation s rom th is
stan dard m an i estation m ay be largely explain ed by th e
variability in h ost respon se to th e in ection .

Coagulase -positive S a ure us Coagulase -ne gative S e pide rm idis

a b c

Fig 3-3a c Diffe re ntiation be twe e n two re late d staphylococci: Sta phylococcus a ure us and Sta phylococcus e pide rm idis. Colonie s of S a ure us
appe ar ye llow (a ), and those of S e pide rm idis are typically smalle r and white r in color (c ). Coagulase is produce d by S a ure us le ading to
coagulation of hum an plasm a (uppe r tube , ( b )). Coagulation is be lie ve d to assist the se bacte ria in avoiding the host de fe nse m e chanism s such
as phagocytosis. Sta phylococcus e pide rm idis, on the othe r hand, is coagulase ne gative and is unable to coagulate human plasma
( lowe r tube ( b )).

31
 Se ct io n 1Principle s
3Microbiology
1.2 En d o ge n o u s a n d e xo ge n o u s in fe ct io n s
Iden ti yin g th e sou rce o th e in ectin g bacteria an d th e m ean s
th rou gh w h ich th e bacteria arrived at th e site o in ection
is o ten an im possible task. Determ in in g th e sou rce o th e
bacteria is n ot n ecessary to per orm an iden ti cation or
diagn osis, alth ou gh an u n derstan din g o th is con cept is im -
portan t. In gen eral term s, th e in ectin g bacteria are con sidered
to arrive at th e site o in ection via on e o tw o proposed
m ean s: eith er rom an en dogen ou s sou rce (ie, a sou rce rom
w ith in th e h ost an d is n orm ally con sidered to in volve h e-
m atogen ou s spread as m ay occu r du rin g bacterem ia) or an
exogen ou s sou rce (ie, via iatrogen ic in ocu lation du rin g
su rgery). Th is con cept is clearly described by Tram pu z an d
colleagu es w h o h ave provided exten sive description in th e
pu blish ed literatu re [1 ]. Accordin g to th is classi ication ,
en dogen ou s in ection s typically in clu de arth ritis, spon dylo-
discitis, or prosth etic join t in ection w ith a h em atogen ou s
sou rce o bacteria. Sin ce th ere is n o requ irem en t or a
su rgical in cision , or n ecessarily an im plan t, th ese in ection s
u su ally requ ire a viru len t path ogen to create th e in ection ,
an d th ere ore o ten resu lt in an acu te in ection . Exogen ou s
in ection s, on th e oth er h an d, m ay be cau sed by low -viru -
len ce organ ism s, as already described, or m ore viru len t
organ ism s th at h appen to be presen t at th e w ou n d or in tro-
du ced du rin g th e w ou n d-h ealin g process. As su ch , th ese
in ection s m ay be eith er acu te or su bacu te/ ch ron ic in n atu re.
32
1.3 Re s is t a n t m icro b e s
Bacterial resistan ce to an tibiotics is on e o th e m ost ch al-
len gin g aspects o treatin g bon e in ection . Nu m erou s actors
m ay accou n t or bacterial resistan ce to an tibiotics ( Ta b le 3-1 ).
Th e m ajority o an tibiotic agen ts on th e m arket w ere origi-
n ally pu ri ed rom soil bacteria th at evolved to produ ce
th ese an tibiotics to com pete w ith oth er bacterial species or
ood or oth er resou rces. As su ch , m an y bacterial popu lation s
h ave coevolved w ith th ese bacteria an d attain ed m ech an ism s
o resistan ce to th ese an tibiotics. An exam ple is th e in trin sic
resistan ce o en terococci to -lactam an tibiotics du e to th e
act th at en terococci m odi y th e protein s to w h ich pen icillin
bin ds [3]. A secon d m ean s o ach ievin g an tibiotic resistan ce
is by acqu irin g th e gen etic in orm ation requ ired to resist an
an tibiotic. A sm all n u m ber o gen es m ay con er th e gen etic
in orm ation requ ired to resist som e an tibiotics, an d it h as
em erged th at m an y o th ese sm all collection s o gen es m ay
be easily sh ared betw een di eren t bacterial species. A prom -
in en t exam ple o su ch an acqu ired resistan ce m ech an ism is
th e spread o m eth icillin resistan ce am on gst staph ylococci.
Th e gen es n ecessary or m eth icillin resistan ce are carried
on a m obile gen etic elem en t n am ed th e staph ylococcal
cassette ch rom osom e m ec. Th is package o DNA is
th ou gh t to h ave origin ated in S epidermidis, w as tran s erred
to S aureus, an d h as sin ce em erged as a prim ary path ogen
o global sign i can ce, in clu din g as a path ogen in bon e in ec-
tion . A som ew h at sim ilar story h as been described or th e
em ergen ce o van com ycin resistan ce in th e en terococci [4].
Resistance eature Example species Antibiotic Re erence
Intrinsic resistance Enterococci -lactam [3 ]
Altered metabolism Escherichia coli Penicillin [5 ]
Reduced penetration Pseudomonas aeruginosa biofilm Tobramycin [6 ]
Intracellular survival Staphylococci Gentamicin [7 ]
Small-colony variants Staphylococci Gentamicin [8 ]
Ta b le 3 -1 Re sistance m e chanism s of bacte ria *.
*
Se le cte d and sim pli e d e xam ple s: the sam e fe ature m ay be valid for
othe r bacte rial spe cie s and othe r antibiotics.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Virginia Post, R Ge off Richards, T Fintan Moriarty
An oth er im portan t m ean s o resistin g an tibiotic th erapy is
via grow th as a bio lm . Bacterial bio lm s h ave been described
to resist an tibiotic con cen tration s over 1,000 tim es h igh er
th an th at described or n on bio lm -grow in g (so-called plan k-
ton ic or ree f oatin g) bacteria. Th is an tibiotic resistan ce m ay
be du e to on e or m ore reason s, w h ich is discu ssed in m ore
detail in ch apter 1 Im plan t-associated bio ilm . In brie ,
bio lm grow th o ers bacteria protection again st an tibiotics
by eatu res su ch as redu ced m etabolic activity w ith in th e
bio lm , redu ced pen etration o an tibiotics du e to th e extra-
cellu lar polym eric su bstan ces th at su rrou n d th e bacterial
cell, an d th e gen eration o ph en otypically distin ct popu la-
tion s w ith distin ct m etabolic activity w ith th e bio lm [9].
Di eren t species m ay exploit th ese di eren t eatu res to a
di eren t exten t, an d, im portan tly, variou s an tibiotics w ill
be m ore, or less, a ected by th ese eatu res th an oth ers. For
exam ple, pen icillin s are on ly active again st m etabolically
active cells sin ce th e target o th e pen icillin s is th e syn th esis
o m acrom olecu les. In a bio lm , w h ere th e syn th esis o su ch
m acrom olecu les m ay be extrem ely low , su ch an tibiotics w ill
n ot h ave an y activity. It sh ou ld be n oted th at th ere are som e
an tibiotics w ith activity again st bio lm , ie, ri am pin again st
gram -positive bio lm s, an d qu in olon es again st gram -n egative
bio lm s.
In tracellu lar su rvival o bacteria h as relatively recen tly
em erged as a poten tial m ean s o resistin g an tibiotic th erapy
in bon e in ection s. Alth ou gh gen erally con sidered extracel-
lu lar path ogen s, th e staph ylococci h ave been described an d
sh ow n to be in tern alized w ith in osteoblasts, w h ere th ey
m ay su rvive, m u ltiply, an d even tu ally kill osteoblasts [10].
Th is can in directly lead to an tibiotic resistan ce, or perh aps
m ay be better described as an an tibiotic avoidan ce strategy
as m an y o th e an tibiotics u sed to treat in ection s do n ot
pen etrate in side h u m an cells. For exam ple, gen tam icin is
on e o th e m ost w idely u sed an tibiotics in local delivery
u sin g bon e cem en t. How ever, th is an tibiotic is u n able to
pen etrate h u m an cells u n less exceedin gly h igh local con -
cen tration s are ach ieved. Th ere ore, an y tissu e-residen t
bacteria m ay be protected rom gen tam icin activity by virtu e
o th eir localization in side a h ost cell.
A n al grou p o bacteria th at display in creased resistan ce
to an tibiotics are th e sm all-colon y varian ts (SCVs) [8]. Sm all-
colon y varian ts are bacteria th at display altered ph en otype
o sm all, slow -grow in g colon ies an d h ave been described
m ost o ten or staph ylococci bu t are also described or
P aeruginosa, E coli, an d salm on ella species. Du e to th e slow
grow in g n atu re an d atypical appearan ce, SCVs m ay be over-
looked in th e clin ical m icrobiology lab. Sm all-colon y varian ts
also pose u rth er treatm en t ch allen ges as th ey typically
display resistan ce again st qu ite a w ide ran ge o an tibiotics
an d also display in tracellu lar su rvival. Th e prevalen ce o
SCVs m ay be in creased in device-associated in ection s a ter
ailed an tibiotic th erapy, bu t tru e in ciden ce is likely u n der-
estim ated du e to th e di cu lty in cu ltu rin g an d iden ti yin g
SCVs.
1.4 Dia gn o s is
Isolation an d cu ltu re ollow ed by an tibiotic su sceptibility
testin g are th e core u n ction s o th e m icrobiology laboratory.
Th e gold stan dard in diagn osis is still bacterial cu ltu re, an d
an tibiotic su sceptibility testin g is also requ ired to en su re an
appropriate th erapy is selected.
Un der m ost circu m stan ces, bacterial species com m on ly
im plicated in bon e in ection s grow qu ite w ell on th e con -
ven tion al agars. Certain bacterial species requ ire particu lar
cu ltu re con dition s to be m et in order to grow in th e lab. Th e
m ost obviou s is th e requ irem en t or exten ded cu ltu re tim e
or slow -grow in g m icroorgan ism s (eg, SCVs) [1 1 ] an d an -
aerobic or m icroaeroph ilic con dition s (eg, or P acnes) [12].
A grow in g body o eviden ce is n ow em ergin g in th e research
literatu re in dicatin g th at bacteria grow in g w ith in a bio lm
m ay n ot be cu ltu rable by con ven tion al m ean s, bu t presen ce
is con rm ed by m odern m olecu lar m eth ods su ch as poly-
m erase ch ain reaction (PCR) an d f u orescen t in situ h ybrid-
ization (FISH) [13 , 14 ]. Th ese m odern tech n iqu es are n ot
rou tin ely available in clin ical h ospitals, bu t th is observation
m ay explain th e rath er h igh rate o cu ltu re-n egative in ec-
tion s observed in m an y clin ical stu dies. Fu rth er details o
th e procedu res or m icrobiological diagn oses w ill be described
in ch apter 7 Diagn ostics.
33
 Se ct io n 1Principle s
3Microbiology

2 Micro o rga n is m p ro file s 2 .1 Gra m -p o s it ive b a ct e ria

Th e ollow in g section w ill describe th e basic eatu res o a
ran ge o th e m ost com m on ly en cou n tered bacteria cau sin g
bon e in ection s. Th e bacteria w ill be grou ped based u pon
gram stain in g ch aracter ( Fig 3 -4 ), aerobic or an aerobic res-
piration , an d a brie m en tion w ill be given to u n gi an d
m ycobacteria, w h ich are less requ en tly en cou n tered, bu t
pose u n iqu e ch allen ges or su ccess u l treatm en t.
Gram -positive bacteria in gen eral con tain a th ick layer o
peptidoglycan in th e cell w all th at en cases th e cell m em bran e
( Fig 3 -4 ). Th is th ick layer retain s th e crystal violet th at orm s
part o th e gram stain in g procedu re. Sin ce th ese bacteria
retain th e stain , th ey are described as gram positive. Prom -
in en t gram -positive bacteria in clu de staph ylococci, strepto-
cocci, an d en terococci.

Cell wall peptidoglycan

Cytoplasmic membrane

Cytoplasm

Periplasmic space

20 m
a

Outer membrane
Cell wall peptidoglycan
Cytoplasmic membrane

Cytoplasm

Periplasmic space
20 m
b
Fig 3-4a b Gram -positive ( a ) and gram -ne gative ( b ) bacte rial ce ll walls.
The diffe re nce in ce ll wall structure accounts for the diffe re nce in ce ll staining which e ithe r re tains crystal viole t and is blue ( a ) or lose s the
stain and is counte rstaine d re d ( b ).

34 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Virginia Post, R Ge off Richards, T Fintan Moriarty

2 .1.1 Sta p h ylo co cci Ch aracteristics: S aureus is on e o th e m ost com m on oppor-

Morph ology: Gram -positive cocci (sph erical cells); cell division
occu rs alon g m u ltiple axes an d th u s orm grape-like clu sters
in plan kton ic grow th ; sm all w h ite to yellow circu lar colon ies
on con ven tion al agars ( Fig 3 -5 ).
Habitat: Skin an d m u cosa (S epidermidis 100% , S aureus 30% ).
tu n istic path ogen s, an d can cau se relatively sim ple skin
in ection s, bu t also li e-th reaten in g sepsis an d en docarditis.
As a m ore viru len t path ogen , S aureus m ay cau se early
in ection s a ter placem en t o a device, or late h em atogen ou s,
acu te in ection s, or prim ary n on im plan t-related osteom y-
elitis [1].

Prom in en t m em bers: S epidermidis; S aureus; Staphylococcus
lugdunensis.
Iden ti cation an d di eren tiation : Di eren tiation m ay be
assisted by th e coagu lase reaction . Coagu lase is an en zym e
th at en ables th e con version o brin ogen to brin resu ltin g
in blood clottin g. Th e en zym e is con sidered to acilitate
in ection by protectin g th e bacteria rom ph agocytosis.
Staphylococcus aureus possesses th is en zym e an d is th u s a
coagu lase-positive staph ylococcu s. Staphylococcus epidermidis
does n ot possess th is en zym e an d is th u s kn ow n as a coag-
u lase-n egative staph ylococcu s.
Most n on -S aureus staph ylococcal in ection s are cau sed by
th e coagu lase-n egative staph ylococci (CoNS) in particu lar
S epidermidis. As low -viru len ce m icroorgan ism s, th e CoNS
m ay h istorically h ave been con sidered con tam in an ts in
in traoperative biopsies. Th e CoNS are h igh ly likely con -
tam in an ts i biopsies are n ot taken in an aseptic m an n er,
h ow ever, th ere is n ow w idespread ackn ow ledgm en t th at
th e CoNS are respon sible or a sign i can t proportion o im -
plan t- related in ection s. As low -viru len ce m icroorgan ism s,
th e CoNS typically cau se late developin g su bacu te in ection s
an d are th u s am on gst th e m ost ch allen gin g to diagn ose.

20 m
a b

c d

Fig 3-5a d Sta phylococcus e pide rm idis.

a Sta phylococcus e pide rm idis form s sm all white colonie s on blood agar.
b c It is a gram -positive coccoid ce ll ( b ) and te nds to form sm all cluste rs due to ce ll division along
two axe s (c ).
d Sta phylococcus e pide rm idis re adily form s bio lm s, which is its primary virule nce m e chanism .

35
 Se ct io n 1Principle s
3Microbiology

Bio lm orm ation is th e prim ary viru len ce actor o CoNS 2 .1.2 Stre p to co cci
an d th ey are am on gst th e m ost proli c bio lm orm in g bac- Morph ology: Gram -positive cocci, cell division occu rs alon g
teria across m edical specialties, n ot on ly in orth opedics an d a sin gle axis an d th u s o ten occu r as ch ain s or pairs o cells
trau m atology. ( Fig 3-6 ).

An oth er CoNS w orth y o m en tion is S lugdunensis, w h ich is
a rath er u n u su al CoNS in th at it retain s qu ite a repertoire
o viru len ce actors en ablin g it to cau se in ection s m ore
resem blin g an acu te S aureus in ection th an a su bclin ical
stereotype in ection o a CoNS.
Most staph ylococci are capable o orm in g a bio lm , an d
w h en grow in g as bio lm , th ese bacteria do n ot respon d to
an tibiotic th erapy. New an tim icrobials targetin g staph ylo-
coccal bio lm s are in vestigated, h ow ever, at presen t, ri-
am pin is th e on ly an tibiotic w ith sign i can t an tibio lm
activity. Ri am pin sh ou ld be on ly u sed in th e proper clin ical
con text an d alw ays in com bin ation w ith an oth er an tibiotic
to m in im ize th e risk o developin g ri am pin resistan ce.
An tibiotic selection or di eren t bacterial path ogen s w ill be
u lly discu ssed in ch apter 5 System ic an tibiotics.
Habitat: Norm al f ora o gastroin testin al tract an d m u cosa.
Prom in en t m em bers: Streptococcus agalactiae; Streptococcus
pyogenes; Streptococcus pneumoniae; Streptococcus viridans.
Iden ti cation an d di eren tiation : Streptococci can be di -
eren tiated based u pon th eir h em olytic activity on sh eep-blood
agar plates. Alph a ( )-streptococci resu lt in in com plete
h em olysis leadin g to a green coloration on agar plates. Beta
()-h em olysis, w h ich is a com plete h em olysis, leads to a
com plete lysis o red blood cells an d clear zon e o h em olysis
on agar plates. Fin ally, gam m a ()-h em olysis is in act a lack
o h em olysis.

20 m
a b

c d

Fig 3-6a d Stre ptococcus spe cie s.

a Stre ptococcus m uta ns growing on blood agar.
b c Stre ptococci usually divide in a single axis and thus appe ar as long chains of gram -positive cocci ( b ).
d Stre ptococci also are capable of form ing bio lm .

36 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Virginia Post, R Ge off Richards, T Fintan Moriarty

Ch aracteristics: -h em olytic streptococci can be su bdivided 2 .1.3 En te ro co cci

in to so-called Lan ce eld grou ps (AG) based on th e carbo-
h ydrate com position in th eir cell w alls. In gen eral, strepto-
coccal bon e an d join t in ection s respon d w ell to treatm en t,
alth ou gh large-scale stu dies ocu sed on th is path ogen are
n eeded [15 ]. Streptococci are capable o bio lm orm ation ,
w h ich is particu larly w ell described in den tal application s,
w h ere th ese streptococcal bio lm s are im plicated in den tal
caries.
Morph ology: Gram -positive cocci grow in g in pairs or sh ort
ch ain s. Cocci m ay elon gate u n der certain grow th con dition s
to a coccobacillu s stru ctu re ( Fig 3 -7 ).
Habitat: Norm al f ora o th e gastroin testin al tract.
Prom in en t m em bers: Most clin ically relevan t species is
E aecalis ollow ed by th e less prevalen t E aecium.

Iden ti cation an d di eren tiation : En terococci are catalase-

n egative an d -h em olytic.

Ch aracteristics: En terococci are robu st bacteria capable o

su rvivin g relatively extrem e en viron m en tal con dition s
(tem peratu re, pH, osm olality). En terococci are capable o
orm in g bio lm an d th eir ten den cy to display sign i can t
in trin sic an d acqu ired an tibiotic resistan ce m akes th em
particu larly ch allen gin g to treat [16]. Van com ycin -resistan t
en terococci (VRE) h ave em erged, ren derin g treatm en t op-
tion s or th ese path ogen s extrem ely lim ited.

20 m
a b

c d

Fig 3-7 a d Ente rococci.

a Ente rococci such as Ente rococcus fa e ca lis form sm all white colonie s on blood agar.
b c The y are usually se e n as pairs or short chains of gram -positive bacte ria ( b ).
The ce lls are usually coccoid, but te nd to display an e longate d structure ( b , c ).
d Ente rococci also de ve lop bio lm s.

37
 Se ct io n 1Principle s
3Microbiology

2 .1.4 Ba cillu s sp e cie s 2 .2 Gra m -n e ga t ive b a ct e ria

Morph ology: Gram -positive, rod-sh aped, en dospore-pro- In con trast to gram -positive bacteria, gram -n egative bacteria
du cin g bacteria ( Fig 3 -8 ). in gen eral possess a cytoplasm ic m em bran e an d an ou ter
cell m em bran e, an d on ly a th in peptidoglycan layer th at
Habitat: Widespread in n atu re. w h ich lies betw een th ese m em bran es. Th is stru ctu re does
n ot retain crystal violet in th e Gram stain an d so stain s gram
Prom in en t m em bers: Bacillus subtilis; Bacillus anthracis; Bacillus n egative ( Fig 3-4 ).
cereus.

Iden ti cation an d di eren tiation : Bacillus species (spp.) can

be obligate aerobes or acu ltative an aerobes. Bacillus in clu des
both ree-livin g (n on parasitic) an d parasitic path ogen ic
species. Un der stress u l en viron m en tal con dition s, th e bac-
teria can produ ce oval en dospores. Th ese ch aracteristics
origin ally de n ed th e gen u s.

Ch aracteristics: Du e to th eir w idespread prevalen ce in n atu re,

Bacillu s spp. can som etim es be detected in open w ou n ds
an d m ay be respon sible or in ection o open ractu res.

20 m
a b

c d

Fig 3-8a d Ba cillus spe cie s.

a Ba cillus ce re us on she e p blood agar plate s are typically large spre ading colonie s.
b c Gram staining shows a gram -positive rod that ofte n form s longe r se rie s of ce lls ( b ).
d Ba cillus spe cie s re adily form s bio lm s.

38 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Virginia Post, R Ge off Richards, T Fintan Moriarty

2 .2 .1 En te ro b a cte ria Ch aracteristics: En terobacteria sh ow di eren t su sceptibility

Morph ology: Gram -n egative rods ( Fig 3 -9 ).
Habitat: Main ly n orm al gu t f ora. En terobacteria can colon ize
open w ou n ds an d can cau se n osocom ial in ection s.
Prom in en t m em bers: Escherichia coli, Klebsiella spp., Proteus
spp., Enterobacter spp., Citrobacter spp., Serratia spp., Morganella
spp., an d Salmonella spp.
Iden ti cation an d di eren tiation : En terobacteria appear as
sm all grey colon ies on blood agar an d gen erally lack cyto-
ch rom e C oxidase. On a ch rom ogen ic m ediu m to aid di -
eren tiation betw een E coli an d oth er coli orm s in cu ltu res,
E coli can be di eren tiated rom oth er coli orm s. Th e
-galactosidase an d -glu cu ron idase activity o E coli resu lts
in pu rple colon ies w ith oth er coli orm s givin g pin k colon ies.
again st an tibiotics, an d th e presen ce o di eren t -lactam ases
can lead to sign i can t an tibiotic resistan ce. Exten ded-spec-
tru m -lactam ase (ESBL) are -lactam ases th at can in activate
th ird- an d ou rth -gen eration ceph alosporin s. Th ey can
com m on ly be ou n d in E coli, Klebsiella pneumonia, an d
Klebsiella oxytoca bu t also som etim es in oth er en terobacteria.
En terobacteria can grow an d orm bio lm on im plan ts. In
vitro stu dies h ave sh ow n th at u sin g qu in olon es are th e m ost
e ective w ay to eradicate en terobacteria in bio lm s, eg,
ciprof oxacin . Ciprof oxacin -resistan t en terobacterial in ec-
tion s w ith im plan ted h ardw are are a sign i can t clin ical ch al-
len ge an d m ay requ ire rem oval o th e im plan t [17].

20 m
a b

c d

Fig 3-9a d Ente robacte ria.

a Ente robacte ria such as Esche richia coli may form m e dium to large colonie s on blood agar.
b The y are consiste ntly gram ne gative .
c The ce lls appe ar as rods.
d Ente robacte ria also de ve lop bio lm s.

39
 Se ct io n 1Principle s
3Microbiology

2 .2 .2 Pse u d om on a s a e ru g in osa 2 .3 An a e ro b ic b a ct e ria

Morph ology: Gram -n egative rods ( Fig 3 -10 ).
Habitat: Soil, w ater, an d skin f ora; colon izes n atu ral an d
arti cial en viron m en ts, open w ou n ds, lu n gs, u rin ary tract,
an d kidn eys. Prom in en t agen t o n osocom ial in ection s.
Iden ti cation an d di eren tiation : P aeruginosa orm s large
grey/ green colon ies on blood agar.
An aerobic bacteria are bacteria th at do n ot requ ire oxygen
or respiration . An aerobic m icroorgan ism s presen t ch al-
len ges to th e m icrobiology laboratory as th ese m icroorgan ism s
m ay n ot tolerate exposu re to oxygen an d m ay n eed to be
rapidly tran s erred to an an aerobic en viron m en t as soon as
a biopsy is taken . In th e absen ce o su ch a rapid tran s er
protocol an d appropriate in cu bation con dition s, an aerobic
m icroorgan ism s m ay lead to a alse-n egative resu lt.

Ch aracteristics: P aeruginosa is n atu rally resistan t to m an y

an tibiotics. Sin ce it is a stron g bio lm orm er, treatm en t o
resistan t strain s is a ch allen ge, particu larly or im plan t-
related in ection s.

20 m
a b

c d

Fig 3-10a d Pse udom ona s a e ruginosa .

a Pse udom ona s a e ruginosa te nds to form large gre y/ gre e n colonie s on blood agar.
b c The y are usually se e n as single gram -ne gative rods ( b , c ) with long
brils (c ).
d Pse udom ona s a e ruginosa also de ve lop bio lm s with signi cant am ounts of e xtrace llular
polym e ric substance s (EPS).

40 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Virginia Post, R Ge off Richards, T Fintan Moriarty
2 .3 .1 Pro p ion ib a cte riu m a cn e s
Morph ology: Gram -positive pleom orph ic rods ( Fig 3-11 ).
Habitat: Norm al skin f ora an d m u cosa.
Prom in en t m em bers: P acnes is th e m ost prom in en t propi-
on ibacteriu m .
Iden ti cation an d di eren tiation : P acnes orm s m ediu m ,
raised o -w h ite to oran ge colon ies on blood agar. In cu ba-
tion u p to 2 w eeks in an an aerobic en viron m en t is requ ired
or optim al cu ltivation .
Ch aracteristics: Propion ibacteria are m ost com m on ly in ter-
preted as con tam in an ts, especially in blood cu ltu res. How -
ever, th ey can be th e cau se o en docarditis or, in orth opedic
cases, prosth esis in ection s [18]. Sin ce propion ibacteria are
slow grow in g, cu ltu res n eed to be in cu bated or at least
2 w eeks.
a b
c d
Fig 3-11 a d Propioniba cte rium a cne s.
a Propioniba cte rium a cne s form s m e dium , raise d off-white to orange colonie s on blood agar.
b c The y are usually se e n as single ple om orphic gram -positive rods ( b ).
d Propioniba cte rium a cne s also de ve lops bio lm s.
2 .3 .2 Clo s trid ia
Morph ology: Gram -positive rods produ cin g spores.
Habitat: Som e belon gin g to th e n orm al gu t f ora oth ers are
ou n d in th e en viron m en t.
Prom in en t m em bers: Clostridium tetani; Clostridium botulinum;
Clostridium per ringens; Clostridium septicum.
Iden ti cation an d di eren tiation : Clostridia can be distin -
gu ish ed rom th e bacilli by lackin g aerobic respiration .
Th ey are obligate an aerobes, ie, oxygen is toxic to th em .
Ch aracteristics: Clostridia produ ce toxin s su ch as th e tetan u s
toxin (C tetani) an d th e botu lin u m toxin (C botulinum).
Clostridium di cile is an im portan t cau se o in testin al disease,
bu t in requ en tly associated w ith bon e in ection s. Th e toxin s
produ ced by C per ringens, C septicum, an d related clostridia
are respon sible or th e typical appearan ce o gas gan gren e.
Clostridia are m ost com m on ly detected in open w ou n ds
su ch as open ractu res.
20 m
41
 Se ct io n 1Principle s
3Microbiology
2 .3 .3 Pe p to s tre p to co cci a n d Fin e go ld ia
Morph ology: Gram -positive cocci.
Habitat: Norm al f ora o gastroin testin al tract, oroph aryn x,
an d skin .
Prom in en t m em bers: Finegoldia magna (previou sly classi ed
as Peptostreptococcus magnus) is th e m ost requ en tly isolated
an aerobic coccu s.
Iden ti cation an d di eren tiation : F magna iden ti cation
depen ds on th e blood cu ltu re system u sed as n ot all rou tin e
protocols w ill iden ti y it [19]. Expert clin ical m icrobiology
laboratory sta are th ere ore requ ired or iden ti cation .
Ch aracteristics: Th ey are o ten regarded as con tam in an ts in
cu ltu res. F magna is im plicated in a ran ge o m on o- an d
polym icrobial in ection s, in clu din g skin an d skin stru ctu re,
bon e an d join t (n ative an d prosth etic join ts) [20], in ective
en docarditis (n ative an d prosth etic valves), n ecrotizin g pn eu -
m on ia, m ediastin itis, an d m en in gitis.
2 .4 Myco b a ct e ria
Morph ology: Acid-alcoh ol ast rods.
Habitat: Water an d soil.
Prom in en t m em bers: Mycobacterium tuberculosis, Mycobacterium
leprae.
Iden ti cation an d di eren tiation : Th e distin gu ish in g ch ar-
acteristic is th at th e cell w all is th icker th an in m an y oth er
bacteria, w h ich is h ydroph obic, w axy, an d rich in m ycolic
acids/ m ycolates. Th e cell w all con sists o th e h ydroph obic
m ycolate layer an d a peptidoglycan layer h eld togeth er by
a polysacch aride, arabin ogalactan .
Ch aracteristics: Som e o th em are path ogen s cau sin g severe
diseases su ch as tu bercu losis (M tuberculosis) an d leprosy (M
leprae). Th e spin e (Potts Disease) is m ost requ en tly a ected
in regards to m u scu loskeletal in ection s by M tuberculosis.
Atypical m ycobacteria are rom th e en viron m en t an d are
regarded as con tam in an ts in clin ical sam ples. Som e species
can cau se in ection s in th e lu n gs an d so t tissu e. Im m u n o-
com prom ised patien ts are m ost com m on ly a ected, an d in
cases w h ere im plan t-related bon e in ection s [21] are in volved,
im plan t rem oval is recom m en ded.
42
2 .5 Fu n gi
Th e clin ically m ost relevan t u n gi are eith er yeast su ch as
Candida spp. or m olds su ch as Aspergillus. Abu n dan t bio lm
orm ation is com m on am on gst th e u n gi, an d im m u n ocom -
prom ised patien ts are m ost com m on ly a ected. Mu scu lo-
skeletal in ection s are rare bu t can h appen directly a ter
in sertion o th e im plan t. All device-related in ection s [22]
w ith u n gi are di cu lt to treat an d rem oval o th e device is
requ ired.
3 Co n clu s io n
Th e m icrobiology laboratory is ch arged w ith providin g an
iden ti cation an d an tibiotic su sceptibility o bacteria with in
tissu e biopsy specim en s. Th e greatest ch allen ge is in di -
eren tiatin g th e gen u in e in ectin g bacteria rom con tam in a-
tion . Con den ce in th e resu lt is best provided by appropriate
sam plin g an d h an dlin g in th e operatin g room an d th e
m icrobiology laboratory.
Th e sam e bacterial species m ay be im plicated in in ection
or con tam in an t. Modern tech n ologies m ay im prove th e
detection o bacteria in tissu e sam ples, bu t th e m ost im por-
tan t u tu re step th at m u st be sou gh t is a m ore con den t
di eren tiation betw een in ection an d con tam in ation .
Un derstan din g th e basic eatu res o bacterial path ogen icity,
in clu din g bio lm orm ation an d tissu e in vasion h elps to
u n derstan d th e clin ical m an i estation o bon e in ection s.
Host actors are o cou rse im portan t, bu t th e viru len ce po-
ten tial o th e di erin g bacteria accou n ts or a sign i can t
portion o th e clin ical m an i estation o th e in ection .
Em ergin g th reats to th e treatm en t o patien ts h as in clu ded
th e in crease in an tibiotic resistan ce w ith in th ese bacteria.
In gen eral, th e m ost di cu lt-to-treat in ection s are bio lm
in ection s, w h ich accou n t or a m assive in crease in an tibi-
otic resistan ce. Obtain in g adequ ate n u m bers o u n con tam -
in ated in traoperative biopsies is th ere ore a key com pon en t
o th e proper diagn osis an d th e care o orth opedic an d
trau m a patien ts.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Virginia Post, R Ge off Richards, T Fintan Moriarty
4 Re fe re n ce s
1. Tra m p u z A, Zim m e rli W. Diagn osis an d
treatm en t o in ection s associated w ith
ractu re- xation devices. Injury. 2006
May;37 Su ppl 2:S59 66.
2. Eich G. Ein e m ik robiologisch e
Orien tieru n gsh il e [A m icrobiological
gu ide]. In : Sw iss Orth opaed ics an d th e
Sw iss Society or In ectiou s Diseases
Ex pert Grou p In ection s o th e
m u scu loskeletal system . In ektionen des
Bewegungsapparates. Gran dvau x: 2014:
166 181.
3. Mu rra y BE. Th e li e an d tim es o th e
En terococcu s. Clin Microbiol Rev. 1990
Jan ;3(1):4 6 65.
4. Ce t in ka ya Y, Fa lk P, Ma yh a ll CG.
Van com ycin -resistan t en terococci. Clin
Microbiol Rev. 2000 Oct;13(4):686 707.
5. Tu o m a n e n E, Co ze n s R, To s ch W, e t a l.
Th e rate o k illin g o Esch er ich ia coli by
beta-lactam an tibiotics is str ictly
proportion al to th e rate o bacterial
grow th . J Gen Microbiol. 1986
May;132(5):12971304.
6. Ts e n g BS, Zh a n g W, Ha rris o n JJ, e t a l.
Th e extracellu lar m atrix protects
Pseu dom on as aeru gin osa bio lm s by
lim itin g th e pen etration o tobram ycin .
Environ Microbiol. 2013
Oct;15(10):2865 2878.
7. He s s DJ, He n r y-St a n le y MJ, Erick s o n
EA, e t a l. In tracellu lar su rvival o
Staph ylococcu s au reu s w ith in cu ltu red
en terocytes. J Surg Res. 2003
Sep;114(1):42 49.
8. Pro ct o r RA, vo n Eiff C, Ka h l BC, e t a l.
Sm all colon y varian ts: a path ogen ic
orm o bacteria th at acilitates
persisten t an d recu rren t in ection s. Nat
Rev Microbiol. 2006 Apr;4(4):295 305.
9. Ho ib y N, Bja rn s h o lt T, Givs ko v M, e t a l.
An tibiotic resistan ce o bacterial
bio lm s. Int J Antimicrob Agents. 2010
Apr;35(4):322 332.
10. Ellin g t o n JK, Re illy SS, Ra m p WK, e t a l.
Mech an ism s o Staphylococcu s au reu s
in vasion o cu ltu red osteoblasts. Microb
Pathog. 1999 Ju n ;26(6):317323.
11. Sch a fe r P, Fin k B, Sa n d o w D, e t a l.
Prolon ged bacter ial cu ltu re to iden ti y
late periprosth etic join t in ection : a
prom isin g strategy. Clin In ect Dis. 2008
Dec 1;47(11):1403 1409.
12. Bu t le r-Wu SM, Bu rn s EM, Po t t in ge r PS,
e t a l. Optim ization o periprosth etic
cu ltu re or diagn osis o
Propion ibacter iu m acn es prosth etic
join t in ection . J Clin Microbiol. 2011
Ju l;49(7):2490 2495.
13. Pa lm e r MP, Alt m a n DT, Alt m a n GT, e t
a l. Can we tru st in traoperative cu ltu re
resu lts in n on u n ion s? J Orthop Trauma.
2014 Ju l;28(7):38 4 390.
14. Ach e rm a n n Y, Vo gt M, Le u n ig M, e t a l.
Im proved d iagn osis o periprosth etic
join t in ection by mu ltiplex PCR o
son ication f u id rom rem oved
im plan ts. J Clin Microbiol. 2010
Apr;4 8(4):1208 1214.
15. Eve rt s RJ, Ch a m b e rs ST, Mu rd o ch DR,
e t a l. Su ccess u l an tim icrobial th erapy
an d im plan t reten tion or streptococcal
in ection o prosth etic join ts. A NZ J
Surg. 200 4 Apr;74(4):210 214.
16. Yu s t e JR, Qu e s a d a M, Dia z-Ra d a P,
e t a l. Daptom ycin in th e treatm en t o
prosth etic join t in ection by
En terococcu s aecalis: sa ety an d
e cacy o h igh -dose an d prolon ged
th erapy. Int J In ect Dis. 2014 Oct;27:65
66.
17. Ro d rigu e z-Pa rd o D, Pigra u C,
Lo ra -Ta m a yo J, e t a l. Gram -n egative
prosth etic join t in ection : ou tcom e o a
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reten tion approach . A large mu lticen tre
stu dy. Clin Microbiol In ect. 2014 Apr 26.
18. Za p p e B, Gra f S, Och s n e r PE, e t a l.
Propion ibacteriu m spp. in prosth etic
join t in ection s: a d iagn ostic ch allen ge.
Arch Orthop Trauma Surg. 2008
Oct;128(10):1039 1046.
19. Ba s s e t t i S, La ife r G, Go y G, e t a l.
En docard itis cau sed by Fin egold ia
m agn a ( orm erly Peptostreptococcu s
m agn u s): d iagn osis depen ds on th e
blood cu ltu re system u sed. Diagn
Microbiol In ect Dis. 2003 Sep;47(1):359
360.
20. Le vy PY, Fe n o lla r F, St e in A, e t a l.
Fin egold ia m agn a: a orgotten path ogen
in prosth etic join t in ection
rediscovered by m olecu lar biology. Clin
In ect Dis. 2009 Oct 15;49(8):124 4 1247.
21. Eid AJ, Be rb a ri EF, Sia IG, e t a l.
Prosth etic join t in ection du e to rapid ly
grow in g m ycobacter ia: report o 8 cases
an d review o th e literatu re. Clin In ect
Dis. 2007 Sep 15;45(6):687694.
22. Azza m K, Pa r vizi J, Ju n gk in d D, e t a l.
M icrobiological, clin ical, an d su rgical
eatu res o u n gal prosth etic join t
in ection s: a m u lti-in stitu tion al
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Nov;91 Su ppl 6:142149.
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44 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Erlangga Yusuf, Olivier Borens
4 Pre ve n tio n o f in tra o p e ra tive in fe ctio n
Erlan gga Yu su f, Olivie r Bo re n s
1 Ba s ics
Th e h ealth care associated in ection s (HCAIs) m ost com -
m on ly a ectin g su rgical patien ts are su rgical-site in ection s
(SSIs), postoperative pn eu m on ia, u rin ary tract, an d blood-
stream in ection s [1 ]. Th is ch apter w ill ocu s m ain ly on
preven tion o SSIs w h ile th e preven tion o oth er HCAIs w ill
be discu ssed alon gside.
Su rgical-site in ection w as previou sly re erred to as w ou n d
in ection w h ich w ou ld in clu de th e in ection o a trau m atic
w ou n d. Th e Un ited States Cen ters or Disease Con trol an d
Preven tion (CDC) th ere ore in trodu ced th e term SSI in 1992
[2 ]. Su rgical-site in ection is de n ed as an in ection th at
occu rs at or n ear th e site o su rgery w ith in 30 days a ter th e
operation [3]. Wh en th e su rgery in volves a prosth etic im plan t,
SSI can occu r u p to 1 year a ter su rgery [4].
Th e CDC recogn izes th ree levels o SSI based on th e depth
o th e in volved tissu es [3 ]. Th e irst level, ie, su per icial
in cision , a ects on ly th e skin an d su bcu tan eou s tissu e. It is
ch aracterized by localized sign s su ch as h eat, redn ess, pain ,
or pu s at th e in cision site. Th e secon d level, ie, deep in cision ,
in volves th e ascial an d m u scle layers. It is ch aracterized by
abscess orm ation , presen ce o pu s, an d ever. Th e th ird
level is th e in ection th at in volves deep organ space su ch as
th e bon e or join t [2].
Th e occu rren ce o SSI a ter orth opedic su rgery depen ds on
m an y variables, su ch as an atom ical location , patien t im -
m u n ity, type o su rgery, an d w h ere th e su rveillan ce is
per orm ed. Su rgical-site in ection rates in a Germ an stu dy
sh ow ed rates o 1.4% or h ip replacem en t an d 1.0% or
kn ee replacem en t [5]. On e su rveillan ce stu dy estim ated th e
occu rren ce o SSIs in orth opedic su rgery at 1.5% w ith 9%
atality [6 ]. An oth er stu dy sh ow ed average SSI rates o
22.7% ran gin g rom 13.2% in clean cases to 70.0% in dirty
w ou n ds [7].
45
 Se ct io n 1Principle s
4Pre ve ntion
of
intraope rative
infe ction

Com pared to n on in ected orth opedic su rgery patien ts,
orth opedic patien ts w ith SSIs stay 2 w eeks lon ger, h ave
dou ble th e rates o reh ospitalization , an d gen erated 300%
greater h ealth -care costs [8].
Categories o risk actors or SSI in clu de: patien t (h ost),
su rgical, an d en viron m en t-related risk actors in th e operatin g
room ( Ta b le 4-1 ); an d organ ism -related risk actors (covered
in ch apters 1 Im plan t-associated bio lm , 2 Host im m u n ity,
an d 3 Microbiology) [3, 9, 10]. Som e patien t-related risk ac-
tors are m odi able. Modi cation o th e patien t-related an d
su rgery-related risks can redu ce rates o SSI. Eviden ce or
preven tion o SSI origin ates rom orth opedics an d oth er
su rgical disciplin es [3, 9, 10].
2 Pre o p e ra t ive m e a s u re s
2 .1 Mo d ifyin g p a t ie n t-re la t e d ris k fa ct o rs
Som e patien t-related risk actors or SSI are m odi able, in -
clu din g diabetes, m orbid obesity, m aln u trition , an d sm okin g.
How ever, th ere is lim ited eviden ce th at sh ow s w h eth er
m odi cation o th ese actors w ill lead to low er SSI rates.
Assessm en t o diabetic patien ts is don e by m easu rin g gly-
coslyated h em oglobin (HbA1c), a reliable in dicator o
diabetic con trol. HbA1c w as u sed in a stu dy to com pare th e
SSIs in patien ts u n dergoin g variou s n on cardiac su rgical
procedu res. It w as sh ow n th at patien ts w ith HbA1c level
less th an 7% h ad a tw o- old low er in ection rate th an
patien ts w ith HbA1c h igh er th an 7% [11 ].

Elective su rgery in patien ts w ith m orbid obesity (body m ass

Patient-related Surgical
Older age Improper patient
preparation prior to surgery
Active infection in other Insufficient hygiene
body site measures of surgical
personnel
History of previous surgery Insufficient surgical
personnel preparation
Poorly controlled diabetes Long surgical duration
mellitus
Malnutrition Tissue damage from surgical Inadequate room
technique cleanliness
Morbid obesity Talking
Smoking Changing gloves
Immunodeficiency Antibiotic infused within
1 hour of incision
Alcoholism Normothermia
Intravenous drug use Surgical personnel not
wearing clean, appropriate
attire
Chronic carrier of
Staphylococcus
Ta b le 4 -1 Factors associate d with surgical-site infe ctions [3 , 9 , 10 ].
Operating room
environment
High operating room traffic
Frequency and duration of
open door
Unclean instruments
Defective ventilation
Poorly designed operating
rooms
in dex (BMI) > 40 kg/ m 2 ) sh ou ld be con sidered care u lly
balan cin g th e risks an d ben e ts [9]. It h as been clearly sh ow n
th at th is popu lation h as a m u ch h igh er SSI risk th an popu -
lation s w ith n orm al w eigh t [12, 13]. Th e h igh risk o SSI is
likely m u lti actorial in clu din g lon ger su rgical tim es, too low
an tibiotic dosin g in obese patien ts, an d a recogn ized im m u n e
system com prom ise associated w ith obesity. Moreover, obese
patien ts o ten h ave com orbidities su ch as diabetes an d
cardiovascu lar diseases. Maln ou rish ed patien ts are also at
in creased risk o SSI [3]. Correction o m aln u trition by total
paren teral n u trition h as been sh ow n to low er postoperative
in ection s in clu din g pn eu m on ia an d u rin ary tract in ec-
tion s [14].
Th e e ect o sm okin g cessation on SSIs in orth opedic pro-
cedu res is readily available. In a Dan ish ran dom ized con -
trolled trial (RCT) in volvin g patien ts u n dergoin g h ip an d
kn ee replacem en t, it was sh own th at patien ts (n = 60) h avin g
qu it or redu ced sm okin g (ie, cou n selin g an d n icotin e re-
placem en t th erapy) 68 w eeks be ore sch edu led su rgery
h ad sign i can tly low er w ou n d-related com plication s th an
con trol patien ts (5% vs 31% , P = .001) [15]. An RCT per-
orm ed in Sw eden reprodu ced th ese resu lts in patien ts w h o
u n derw en t h ip or kn ee replacem en t, prim ary h ern ia repair,
an d laparoscopic ch olecystectom y [16].
Several oth er poten tially m odi able patien t-related actors
h ave been discu ssed in CDC gu idelin es [3] an d at th e In ter-
n ation al Con sen su s Meetin g on Periprosth etic Join t In ection
[9] bu t th e eviden ce is n ot clear. Th ese risk actors are in tra-
ven ou s dru g abu se, alcoh ol abu se, im m u n osu ppressive
m edication , an d h u m an im m u n ode icien cy viru s (HIV)
in ection . Th e decision to per orm su rgery in th ese patien ts
sh ou ld be don e on an in dividu al basis.

46 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Erlangga Yusuf, Olivier Borens
Th e presen ce o active in ection eith er in a join t or in th e
bloodstream is associated w ith in creased SSI risk in join t
replacem en t su rgery [17 , 1 8 ]. Screen in g or th e presen ce o
in ection an yw h ere in th e body is th ere ore recom m en ded.
Th ere is a stron g con sen su s am on g orth opedic su rgeon s to
avoid elective arth roplasty in patien ts w ith an y active in ec-
tion [9 ]. Most orth opedic su rgeon s avoid elective arth ro-
plasty in patien ts w ith active skin u lceration s. Th ere is
lim ited eviden ce th at skin u lceration s pose a risk or SSI
[9 ]. Th e presen ce o bacteria in th e u rin e (asym ptom atic
bacteriu ria) is an oth er relevan t issu e. It h as been sh ow n
th at asym ptom atic bacteriu ria be ore su rgery was associated
w ith in creased risk or su bsequ en t prosth etic join t in ection
[19]. In terestin gly, an tibiotic th erapy did n ot redu ce th is risk
[1 9 ]. It can be in erred rom th is stu dy th at it is sa e to
per orm total join t arth roplasty (TJA) in patien ts w ith
asym ptom atic bacteriu ria w ith ou t speci cally eradicatin g
th e bacteria. Rou tin e u rin e screen in g is also th ere ore n ot
w arran ted or patien ts u n dergoin g elective arth roplasty [9].
Wh en a TJA is plan n ed an d th e patien t is ou n d to h ave
asym ptom atic bacteriu ria, th e operation can take place as
lon g as rou tin e proph ylactic an tibiotics are given .
2 .2 Na s a l d e co lo n iza t io n
As sh ow n in ch apter 3 Microbiology, th e m ajority o SSIs
resu lt rom Staphylococcus aureus [20 ] an d decolon ization is
believed to redu ce th e n u m ber o SSIs. On e o th e m ain
reservoirs o S aureus is th e n ares. Th e m ost exten sively
stu died an d u sed agen t or eradication o S aureus sin ce th e
1980s is m u pirocin [21 , 22 ]. It is a poten t decolon izin g agen t
w h ich is also active again st oth er gram -positive bacteria.
Nasal carriage w as elim in ated w ith in 96 h ou rs a ter com ple-
tion o treatm en t in arou n d 90% o stu dy popu lation s [23].
Mu pirocin is u su ally applied to th e an terior n ares 23 tim es/
day, or 25 days [24 , 25 ]. It h as been sh ow n th at m u pirocin
can also be u sed to eradicate m eth icillin -resistan t S aureus
(MRSA) [25 ]. In orth opedic su rgery, u se o m u pirocin tw ice
daily rom th e day be ore su rgery u n til th e day o su rgery
h as been sh own to lower rates o SSI with iden tical S aureus
isolate [26]. Th ere are several draw backs w h en u sin g m u pi-
rocin , su ch as recolon ization , th e developm en t o resistan ce,
an d cost. In a stu dy on h ealth y h ospital sta , a ter n ear
com plete decolon ization im m ediately ollow in g m u pirocin
u se, th e colon ization w as 56% an d 53% a ter 6 m on th s an d
1 year, respectively [27]. In creased u se o m u pirocin correlates
to th e developm en t o resistan ce [28]. Th e u se o m u pirocin
sh ou ld th ere ore w arran t care u l m on itorin g an d altern a-
tives sh ou ld be in vestigated. For exam ple, on e altern ative
agen t or n asal decolon ization o S aureus u n der in vestigation
is retapam u lin [24].
2 .3 Cle a n s in g t h e s k in
Skin is n orm ally colon ized by a ran ge o m icroorgan ism s.
Th e su rgical skin in cision can in trodu ce th e m icroorgan ism s
to th e exposed tissu e an d m ay resu lt in SSI. Several stu dies
h ave sh ow n th at skin clean sin g can rem ove th e m icroorgan -
ism s [29, 30]. How ever, th e e ect o skin clean sin g on SSI
rates is less clear. A system atic review in clu din g on e RCT,
tw o coh ort stu dies, an d tw o in terven tion al stu dies, sh ow ed
a sign i can t redu ction in SSI risk (pooled relative risk o
0.29 (95% con den ce in terval (95% CI o 0.17 to 0.49)
w h en ch lorh exidin e glu con ate w ash cloth s w ere com pared
w ith eith er n o in terven tion or oth er clean sin g agen t, su ch
as soap-w ater bath , or povidon e-iodin e scru b [31]. Yet, m an y
o th e stu dies in clu ded in th is system atic review w ere n ot
ree rom bias. In con trast to th is system atic review , a m eta-
an alysis u sin g Coch ran e stan dards on RCTs th at in clu ded
10,157 participan ts did n ot sh ow statistically sign i can t
redu ction in SSI w h en 4% ch lorh exidin e glu con ate w as
com pared w ith a placebo, or w ith u sin g a bar o soap, or
with n o wash in g [32]. It can be con clu ded th at skin clean sin g
can rem ove th e m icroorgan ism s rom th e skin , bu t th e e ect
o th is m easu re on SSI is n ot clear. Despite th e lim ited
eviden ce, skin clean sin g is w idely u sed an d approved o by
orth opedic su rgeon s [9].
Skin clean sin g sh ou ld be per orm ed over th e w h ole body
an d n ot on ly at th e su rgical site [9]. A stu dy o 1,530 opera-
tion s or biliary tract disease, in gu in al h ern ia, an d breast
can cer sh ow ed th at th e in ection rate w as low er or w h ole-
body th an su rgical-site-speci c w ash in g [33]. Regardin g th e
requ en cy an d tim in g o skin clean sin g, th e CDC recom m en ds
preoperative sh ow erin g on at least th e n igh t be ore th e
operative day [3]. Th e regim en s o skin clean sin g th at are
o ten described are skin clean sin g tw ice, ie, a cou ple o days
be ore an d on th e m orn in g o th e operation [34, 35]. Ch lorh ex-
idin e sh ou ld n ot be u sed excessively sin ce th is can also lead
to skin irritation [36].
Man y stu dies u se ch lorh exidin e glu con ate as an agen t or
skin clean sin g. Th e CDC recom m en ded ch lorh exidin e 2%
as th e agen t o ch oice to redu ce cath eter-related bloodstream
in ection [37], bu t a speci c recom m en dation to u se ch lorh ex-
idin e to redu ce SSIs h as n ot been m ade [3].
47
 Se ct io n 1Principle s
4Pre ve ntion
of
intraope rative
infe ction

2 .4 Ha ir re m o va l
Tradition ally, th e preparation o a patien t or su rgery in -
clu ded rem oval o h air rom th e in cision site. Th e pu blish ed
literatu re on th e e ect o h air rem oval on SSIs in orth opedic
procedu res is very lim ited an d th e kn ow ledge is derived
rom oth er su rgical elds [38]. Th e CDC does n ot recom m en d
h air rem oval preoperatively u n less th e h air w ill in ter ere
w ith th e operation [3]. Th is recom m en dation is su pported
by a m etaan alysis th at ou n d n o statistically sign i ican t
di eren ce in SSI rates betw een rem oval o body h air by
sh avin g, clippin g, or depilatory cream , an d n o h air rem oval.
Notew orth y, is th at th e com parison in th is m etaan alysis is
u n derpow ered as m en tion ed by th e au th ors o th is m eta-
an alysis [38].
Wh en h air rem oval is per orm ed, clippin g is pre erred to
u se o a razor as sh ow n in tw o stu dies per orm ed in th e
1980s [39 . 4 0 ]. Th e au th ors specu late th at abrasion s orm ed
du e to sh avin g can becom e sites o bacterial grow th w h ich
can lead to in ection . Th ere is lim ited data on oth er m eth ods
o h air rem oval, eg, depilatory cream . Th e h air rem oval
sh ou ld be per orm ed in th e h ospital as close to th e tim e o
su rgery as possible by eith er th e su rgical team or th e n u rsin g
sta [9]. Th is recom m en dation is based m ore on practicality
th an on scien ti c eviden ce. Tw o stu dies in th e 1970s an d
1980s, w h ich did n ot speci cally look at th e tim in g o h air
rem oval, sh ow ed th at h air rem oval on th e m orn in g o or
im m ediately be ore su rgery w as associated w ith a low er SSI
rate th an sh avin g 24 h ou rs or m ore prior to su rgery [40 , 4 1].
2 .5 An t is e p t ic s k in p re p a ra t io n in t h e o p e ra t in g
ro o m
Th e prin ciple o aseptic su rgery is on e o th e m ost im portan t
developm en ts in su rgery. Th is prin ciple w as described by
Joseph Lister (18271912). He applied th e advan ces in
m icrobiology by an oth er gian t in th e eld o m icrobiology
an d in ection con trol, Lou is Pasteu r, to su rgery by prom ot-
in g th e idea o sterile su rgery [42]. He u sed carbolic acid to
clean w ou n ds, w h ich led to a redu ction in SSI. Prior to th is
period, lim b am pu tation or exam ple, w as associated w ith
a distu rbin g 50% m ortality du e to sepsis [43].
Th e pu rpose o skin preparation in th e operatin g room is to
rem ove soil an d tran sien t bacteria rom th e skin [44]. It can
be don e by application o an tiseptic. Th e an tiseptic sh ou ld
be applied u sin g a dedicated sterile an d sin gle-u se in stru -
m en t, eg, spon ge, in th e area th at sh ou ld be large en ou gh
to in clu de an y poten tial exten sion o th e in cision site rom
th e m ain in cision [3, 44]. Th e application sh ou ld be per orm ed
in con cen tric circles rom th e in cision site m ovin g tow ard
th e periph ery [44 ]. Th e reason or th is m ovem en t is practi-
cal, to redu ce th e am ou n t o residin g m icroorgan ism s at th e
su rgical site.
Th e CDC [3 ] an d Association o Operatin g Room Nu rses
(AORN) [4 4 ] gu idelin es recom m en d on ly liqu id produ cts
an d again st n on liqu id produ cts, su ch as pow der sprays or
im pregn ated drapes [3 , 4 4 , 4 5]. Th ere are th ree com m on ly
u sed skin an tiseptics [45, 46] ( Ta b le 4-2 ).

Povidone-iodine Alcohol Chlorhexidine gluconate

E f cacy Gram-positive bacteria Excellent Excellent Excellent

Gram-negative bacteria Excellent Excellent Good

Acid-fast bacillus Excellent Good Minimal

Sporicide Partial No

Fungi Excellent Partial Minimal

Viruses Excellent Partial (RSV, Hepatitis B, HIV) HIV, HSV, CMV, influenzae

Mode o action Cell-wall penetration, oxidation, and Denaturation of cell-wall proteins of bacteria Disruption of cell membranes and
substitution of microbial contents with iodine precipitation of cell contents
Formulation 510% (w/v) that contain 0.51% iodine 7090% (w/v) 0.54% (w/v)
Major advantage Rapid
Major disadvantage Possible skin irritation and damage No residual effect

Ta b le 4 -2 The thre e m ost com m only use d skin antise ptics [4 5 , 4 6 ].

Abbre viations: w/ v, we ight pe r volum e; HIV, hum an imm unode cie ncy virus; RSV, re spiratory syncytial virus; HSV, he rpe s sim ple x virus; CMV,
cytom e galovirus.

48 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Erlangga Yusuf, Olivier Borens
Th e rst an tiseptic is iodin e based. Typically, iodoph ors th at
com prise ree iodin e m olecu les are bou n d to a polym er su ch
as povidon e [47] to redu ce th e irritation e ect o iodin e [48].
In th e m ajority o Eu ropean h ospitals, povidon e-iodin e is
th e m ost com m on ly u sed an tiseptic [49]. Povidon e-iodin e is
solu ble in both w ater an d alcoh ol. Th e secon d-m ost com -
m on ly u sed is alcoh ol. Its e ectiven ess depen ds m ain ly on
its con cen tration [47]. Th e th ird is ch lorh exidin e glu con ate.
Like povidon e-iodin e, it is available in aqu eou s an d alcoh ol
orm u lation s. Th ere is lim ited eviden ce th at ch lorh exidin e
is better th an th e oth ers in redu cin g SSI rates in clean
su rgery [45]. Com parison betw een th e an tiseptic agen ts is
di cu lt becau se iodoph or an d ch lorh exidin e glu con ate are
available in com bin ation w ith alcoh ol. Th ere ore, th e e -
cacy o ch lorh exidin e glu con ate can n ot be attribu ted solely
to ch lorh exidin e glu con ate [46 ]. Th e com bin ation o 2%
ch lorh exidin e glu con ate an d 70% isopropyl alcoh ol is sh ow n
in a RCT in volvin g 897 patien ts (n o orth opedic procedu res
w ere in clu ded) to be su perior to aqu eou s solu tion o 10%
povidon e-iodin e [50]. Th e selection o an tiseptic scru bs sh ou ld
con sider ch aracteristics su ch as costs an d poten tial side e -
ects. Th ere is a lim ited n u m ber o stu dies on th e agen ts o
ch oice or an tiseptic scru bbin g in con tam in ated su rgery [51].
In broken skin , an tiseptics can also be u sed bu t n ot iodoph or
sin ce it m ay h ave a n egative e ect on tissu e h ealin g [48].
2 .6 Dra p in g p a t ie n t s
Ideally, su rgical drapes sh ou ld be im perm eable to liqu ids
an d im perviou s to tearin g [5 2]. Th ere are disposable an d
reu sable su rgical drapes. Th ere is n o eviden ce th at on e type
is better th an th e oth er in preven tin g SSI accordin g to th e
resu lts o a RCT w ith 494 participan ts [53]. Su rgical drapes
can be kept in place by u sin g adh esivesa tran sparen t plas-
tic sh eet adh erin g to th e skin . It h as been sh ow n th at th ey
preven t bacterial pen etration in h ip ractu re su rgery [5 4 ]
an d preven t th e skin bacteria rom m u ltiplyin g u n der th e
drape [55] (Fig 4-1 ) . Yet, th ere is n o eviden ce th at th ey redu ce
SSI rates [5 6]. Th e adh esive plastic drape is also available
im pregn ated w ith iodin e. Th ere is n o eviden ce th at adh esive
drapes are better th an n ot u sin g an adh esive drape [56].
2 .7 Ha n d h ygie n e o f s u rgica l p e rs o n n e l
Th e Hu n garian ph ysician Ign az Sem m elw eis (18181865)
discovered th at th e in ciden ce o pu erperal ever cou ld be
sign i can tly low ered by u sin g h an d disin ection in obstetri-
cal clin ics. Han d h ygien e h as sin ce been recogn ized as th e
m ost im portan t m easu re to preven t HCAIs.
Tw o option s are available or su rgical person n el or th e
preoperative treatm en t o h an ds, w h ich sh ou ld in clu de n ails,
h an ds, an d orearm s [57]. Th e rst option is w ash in g o h an ds
w ith an tim icrobial soap an d w ater: su rgical h an d-an tiseptic
soaps (scru b). Th e secon d option is th e application o an
alcoh ol-based h an d liqu id applied on to dry h an ds w ith ou t
w ater: su rgical h an d disin ection (ru b) [57].
Fig 4-1 Surgical drape s.
49
 Se ct io n 1Principle s
4Pre ve ntion
of
intraope rative
infe ction
Su rgical h an d scru bbin g is aim ed at rem ovin g tran sien t
organ ism s, ie, m icroorgan ism s th at can be isolated rom th e
skin bu t are n ot con sisten tly presen t in th e m ajority o
person n el, su ch as Escherichia coli an d Pseudomonas aerugi-
nosa, an d at redu cin g com m en sal f ora, ie, perm an en t f ora
o th e skin su ch as Propionibacterium species, Corynebacterium
species, an d coagu lase-n egative staph ylococci [47, 58]. Th is
is n ecessary becau se even low levels o con tam in ation can
cau se in ection s, especially in im plan t su rgeries [58]. Hospital
gu idelin es o ten recom m en d th e u se o a spon ge or bru sh
or su rgical h an d scru bbin g. Th e u su al agen ts or th is pu rpose
are w ater-based solu tion s or soap th at con tain ch lorh exidin e
or povidon e-iodin e [43, 61]. Ch lorh exidin e-glu con ate based
aqu eou s solu tion s seem s to be m ore e ective in redu cin g
th e n u m ber o colon y- orm in g u n its on th e h an ds th an
povidon e-iodin e-based aqu eou s scru bs [61]. Th e du ration
o su rgical scru b is o ten a part o h ospital recom m en dation s.
It h as lon g been th ou gh t th at lon ger scru bbin g w as m ore
e ective, bu t it h as been sh ow n th at scru bbin g or 35 m in -
u tes sh ou ld redu ce bacterial cou n ts to acceptable levels.
Lon ger du ration o scru bbin g does n ot give an added e ect
an d w ill on ly in crease th e risk o skin dam age [59, 60].
An altern ative or su rgical scru b is alcoh ol-based h an d ru b.
Here, su rgical h an d disin ection is per orm ed w ith ou t u sin g
bru sh es or spon ges. Th is altern ative is an in terestin g option
becau se it m ay in crease com plian ce an d is aster to per orm
[58]. Bru sh less su rgical h an d an tiseptics can be per orm ed
u sin g alcoh ol w ith a con cen tration o 6095% . Th e th ree
m ain alcoh ols u sed are eth an ol, isopropan ol, an d n -propan ol
[61, 62]. Ch lorh exidin e, iodin e, an d oth er active in gredien ts
can be added to th e su rgical h an d disin ectan t solu tion s. It
h as been sh ow n in on e trial th at alcoh ol-based disin ectan ts
are as e ective as aqu eou s scru bbin g in preven tin g SSIs [63]
bu t th ere is n o eviden ce th at su ggests th at an y particu lar
alcoh ol is better th an an oth er [61].
50
2 .8 Su rgica l a t t ire fo r s u rgica l p e rs o n n e l
An y sim ple m ovem en t can liberate m icroorgan ism s rom
th e skin an d rom casu al cloth in g [64]. Th e con sen su s is to
w ear su rgical scru b cloth es, m asks, an d su rgical caps to
m in im ize th e tran s er o m icroorgan ism s rom su rgical team
m em bers to th e patien ts an d to th e operatin g room en viron -
m en t ( Fig 4 -2 ). How ever, th e scien ti c eviden ce or th ese
m easu res to preven t SSIs is lackin g [3, 65, 66]. Masks belon g
to th e stan dard su rgical attire. In deed, it h as been sh ow n
th at bacteria can be dispersed via talkin g [64, 67]. How ever,
in an in terestin g stu dy w h ere th e participan ts w ere requ est-
ed to talk w h ile a cu ltu re plate placed on e m eter rom th ese
volu n teers, it w as sh ow n th at m ou th bacteria cou ld n ot
disperse to th at distan ce [68]. Despite th is observation , w ear-
in g m asks or su rgical person n el is requ ired sin ce th ey stan d
closer to th e patien t th an on e m eter, both to protect th e
patien t an d su rgical team rom con tam in ation .
Clean su rgical garm en ts sh ou ld be u sed an d th ey sh ou ld be
w ash ed in th e h ealth acilities rath er th an at h om e. Th e
practice o w ash in g scru b cloth in g at h om e still occu rs in
several cou n tries su ch as in th e US. Th e garm en ts sh ou ld
n ot be f am m able, an d sh ou ld n ot h arbor du st or droplets
[69].
Gloves are th e on ly item o attire th at is scien ti cally sh ow n
to redu ce SSI rates. Wh en gloves are per orated du rin g a
procedu re, it can lead to tw ice th e SSI risk [70 ]. In abou t 9%
o orth opedic su rgeries, gloves are per orated [70] an d in th e
m ajority o cases glove per oration is n ot recogn ized du rin g
su rgery [71]. It is th ere ore advisable to u se dou ble gloves
to im prove th e sterile barrier betw een su rgeon an d patien t,
even th ou gh th is w ill redu ce tactile sen sation .
Fig 4-2 The surge on in scrub attire .
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Erlangga Yusuf, Olivier Borens
3 In t ra o p e ra t ive m e a s u re s
3 .1 At ra u m a t ic s u rgica l t e ch n iq u e
Atrau m atic su rgical tech n iqu e is an essen tial clin ical practice
th at sh ou ld in th eory redu ce th e risk o SSI. Th e su rgeon
sh ou ld m in im ize th e am ou n t o tissu e dam age, h an dle tissu e
w ith care, w h ile m ain tain in g th e patien ts tem peratu re,
oxygen ation , an d per u sion . Gen tle w ou n d closu re an d drain -
age are actors th at can preven t SSIs. Moreover, keepin g th e
du ration o su rgery as sh ort as possible m igh t preven t SSIs.
Su rgical in cision s can be m ade by u sin g scalpel an d/ or
electrocau tery. In m an y in stitu tion s separate blades are u sed
or skin in cision versu s in cision in to deeper tissu e or h igh -
risk su rgeries. Th ere is lim ited scien ti c eviden ce or th is
practice. Skin blades can be con tam in ated u p to 15% a ter
skin in cision ; m u ch o th e con tam in ation con sists o coag-
u lase-n egative staph ylococci, on e o th e cau ses o prosth etic-
join t in ection [72]. On th e oth er h an d, it is sh ow n th at even
i th e kn i e blades are con tam in ated, th ey do n ot lead to
tran s er o th e bacteria to th e wou n d edges an d th e deeper
tissu e [73]. Com pared to scalpel, electrocau tery is aster an d
cau ses less bleedin g. Th e SSI rate in a sm all stu dy in volvin g
60 patien ts sh ow ed th at th e SSI rates in patien ts w h o u n -
derw en t scalpel an d electrocau tery or skin in cision s, w ere
com parable [74].
Du rin g su rgery, tissu e sh ou ld be h an dled gen tly an d devital-
ized tissu e an d debris sh ou ld be rem oved. Irrigation can also
rem ove in f am m atory m ediators an d dilu te con tam in ation
[7 5 ]. Th ere are variation s in practice in term s o volu m e,
pressu re, an d tech n iqu es as w ell as w h ich solu tion sh ou ld
be u sed. Argu ably, in creased volu m e w ill im prove w ou n d
clean sin g, bu t n o optim al volu m e h as been recom m en ded
[9, 75]. High - or low -pressu re lavage can be per orm ed. Stu d-
ies h ave u sed variou s de n ition s o h igh an d low pressu re.
Pressu re below 15 psi (103.4 kPa) can be con sidered as low
pressu re an d over 35 psi (241.3 kPa) as h igh pressu re [76].
In th eory, h igh -pressu re lavage can rem ove th e debris an d
th e n ecrotic tissu e rapidly, an d w ill allow better cem en t
pen etration in can cellou s bon e tissu e in cem en ted arth ro-
plasty [9]. Th e draw back o u sin g h igh -pressu re lavage is th e
possible dam age to tissu e an d deeper pen etration o bacteria
as sh ow n in an in vivo stu dy [76]. Argu ably, h igh -pressu re
lavage sh ou ld be ben e cial in severely con tam in ated w ou n ds
or in open in ju ries. How ever, th e m ajority o su rgeon s in an
in tern ation al su rvey o 984 su rgeon s m ain ly rom Can ada
an d rom an in tern ation al ractu re cou rse (AO Fou n dation ,
Davos, Sw itzerlan d), avored low -pressu re lavage or th e
in itial m an agem en t o open ractu re w ou n ds [77]. Salin e can
be u sed or th e lavage an d is pre erred by m an y su rgeon s
[77]. Addition al in orm ation on irrigation can be ou n d in
ch apter 6 Local delivery o an tibiotics an d an tiseptics.
Main tain in g adequ ate tissu e oxygen ation seem s to be im -
portan t in preven tin g SSIs. Oxygen ation plays an im portan t
role in im m u n e u n ction , especially in oxidative killin g o
m icroorgan ism s by n eu troph ils. Th ere are several possibilities
to im prove tissu e oxygen ation in clu din g n orm oth erm ia [78],
u se o su pplem en tal oxygen [79], an d by m ain tain in g cardiac
ou tpu t du rin g th e su rgery [80]. Am on g th ese possibilities,
stu dies h ave sh ow n th at n orm oth erm ia [78] an d su pplem en -
tal oxygen [79] are associated w ith low er SSIs com pared to
h ypoth erm ia an d n o su pplem en tal oxygen , respectively.
How ever, extra f u id adm in istration does n ot decrease SSI
rates [80]. Th is eviden ce is based on a very lim ited n u m ber
o stu dies.
Wh en th e odds o in ection are low , trau m atic w ou n ds sh ou ld
be closed [81]. Th ere are several possibilities or closu re su ch
as su tu res an d staples. Tissu e adh esives are also available,
bu t th ey m ay lack m ech an ical stren gth an d perh aps sh ou ld
be con sidered as a biological sealan t [9]. Closu re m aterial,
like an y oth er oreign m aterial, can prom ote m icroorgan ism
grow th [82]. Su tu res can be rou gh ly divided in to absorbable
an d n on absorbable. Absorbable su tu res are m ade rom
variou s m aterials su ch as polyglycolic acid, polyglactic acid,
polydioxan on e, polytrim eth ylen e carbon ate, an d catgu t.
Th e absorbable su tu res are com pletely absorbed betw een
60210 days [83 ]. Wh en absorbable su tu re can n ot be u sed,
or exam ple, du e to in ection in th e su rrou n din g tissu es,
n on absorbable su tu res can be u sed [81]. Exam ples o n on -
absorbable su tu res are n ylon , polypropylen e, braided poly-
ester, polybu tester, an d silk [8 3 ]. A stu dy u sin g a m ou se
m odel sh ow ed th at syn th etic su tu res w ere better th an
n atu ral su tu res in resistin g gram -positive an d gram -n egative
bacteria [84]. Absorbable an d n on absorbable su tu res can be
m on o lam en ts or braided. Com pared to m on o lam en ts,
braided su tu res allow easy h an dlin g, bu t probably at th e
cost o h igh er risk or in ection . It is sh ow n in a m ou se
m odel th at braided su tu res resist bacteria less th an m on o-
lam en t su tu res [8 4]. Moreover, bacteria th at reside in a
bio lm in a braided su tu re are protected rom ph agocytosis
becau se leu kocytes can n ot pen etrate reely in to th e braided
su tu res [85].
51
 Se ct io n 1Principle s
4Pre ve ntion
of
intraope rative
infe ction
To close th e w ou n d, staples can also be u sed. Like su tu res,
th ey are absorbable or n on absorbable (ie, stain less steel).
Con tam in ated w ou n ds closed w ith staples are associated
w ith ew er SSIs w h en com pared to w ou n ds closed w ith
su tu res [86]. Th ere is n o con sen su s am on g orth opedic su r-
geon s on th e best m eth od o closu re to preven t SSIs [9]. A
m etaan alysis th at in clu ded six sm all-sized stu dies ( ve o
six stu dies in volved su rgery o th e h ip) sh ow ed m ore th an
a th ree- old in crease in SSIs in stapled w ou n ds com pared
w ith su tu red w ou n ds [87]. Th e resu lts o th is m etaan alysis
sh ou ld be in terpreted cau tiou sly becau se o m eth odological
lim itation s o th e in clu ded stu dies, su ch as in adequ ate an d
varied de n ition o SSI [87]. Adh esives, su ch as 2-octylcya-
n oacrylate can be u sed to seal th e w ou n d. Th ere are a lim -
ited n u m ber o stu dies th at in vestigate th e SSI rates w ith
adh esives in com parison to staples or su tu res. Kh an an d
colleagu es com pared 2-octylcyan oacrylate, su bcu ticu lar
su tu re (m on ocryl), an d skin staples in 102 h ip replacem en ts
an d 85 o th e kn ee [88]. Th ey sh ow ed th at 2-octylcyan oac-
rylate w as associated w ith less w ou n d disch arge in th e rst
24 h ou rs or both th e h ip an d th e kn ee [88].
Delayed prim ary closu re sh ou ld be per orm ed in h igh ly
con tam in ated w ou n ds [89]. Sin ce th e rst ran dom ized stu dy
on th is topic pu blish ed in th e 1960s [9 0 ], several oth er
stu dies [91 93 ] h ave sh ow n th e ben e cial e ect o delayed
prim ary closu re in abdom in al operation s. Th e proo o prin -
ciple o th e delayed prim ary closu re w as establish ed in 1933,
w h ere it w as sh ow n th at application o S aureus to su rgical
w ou n ds in gu in ea pigs on day 5 to day 7 gave less in ection
th an w h en th e bacteria w as applied earlier [94]. In patien ts
w ith open ractu res, delayed closu re h as n ot been sh ow n
to be m ore ben e cial th an prim ary closu re [95]. Th e u se o
52
proph ylactic an tibiotics an d preem ptive an tibiotic th erapy
in open ractu res m igh t con ou n d th is research .
Th e con cept o delayed prim ary closu re h as been exten ded,
or exam ple, by u sin g n egative-pressu re w ou n d th erapy
[89]. It is u sed as a bridge to close con tam in ated w ou n ds an d
is sh ow n in an im al stu dies to redu ce bacterial load in th e
w ou n d [96 , 97 ]. In terestin gly, in a stu dy in patien ts w ith
ch ron ic w ou n ds it w as sh ow n th at th e n egative-pressu re
w ou n d th erapy oam s w ere h eavily colon ized by bacteria,
despite rou tin e replacem en t o th e oam [98].
A drain can be u sed to evacu ate f u ids an d h em atom a rom
w ou n ds or body spaces. Flu ids an d h em atom ata can im pair
w ou n d h ealin g by in creasin g pressu re. Th e in creasin g pres-
su re can su bsequ en tly lead to problem s in tissu e per u sion
[99]. A drain , on th e oth er h an d, is also a oreign body an d
can act as a con du it or in ection . Th is dilem m a h as been
in vestigated by several stu dies in orth opedic procedu res. A
system atic review o ve RCTs in volvin g 349 patien ts did
n ot sh ow sign i can t di eren ce in th e u se o closed su ction
drain s ollow in g an terior cru ciate ligam en t recon stru ction
su rgery [100]. An oth er system atic review th at in clu ded six
RCTs in volvin g 664 patien ts also sh ow ed th at th e u se o
closed su ction drain s did n ot in crease SSI rates ollow in g
h ip ractu re su rgery [101].
Th e du ration o su rgery sh ou ld be kept as sh ort as possible
to preven t SSIs. It h as been sh ow n th at in total kn ee arth ro-
plasty, prolon ged du ration o su rgery is a risk actor or SSI
[1 0 2 , 1 0 3 ]. Th e in creased du ration o su rgery can be con -
ou n ded by th e oth er SSI risk actors su ch as obesity an d
w ash ou t o proph ylactic an tibiotics.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Erlangga Yusuf, Olivier Borens
3 .2 Ke e p in g co n t a m in a t io n in t h e o p e ra t in g ro o m
e n viro n m e n t a s lo w a s p o s s ib le
Th e operatin g room en viron m en t can h arbor path ogen s.
For exam ple, staph ylococci h ave been isolated rom air
sam ples o th e operatin g room [1 0 4 ]. In prosth etic join t
su rgery th ere is a correlation betw een air con tam in ation in
th e operatin g room an d prosth etic join t in ection [10 5 ]. Th e
operatin g room sh ou ld th ere ore be properly ven tilated to
m in im ize airborn e m icroorgan ism s [106]. Th is can be don e
by applyin g positive pressu re in th e operatin g room w ith
respect to corridors an d adjacen t areas. Positive pressu re
preven ts airf ow rom less clean in to m ore clean areas [107].
Usin g th e sam e logic, airf ow sh ou ld go rom th e ceilin g to
th e f oor [3].
An in terestin g issu e or th e orth opedic eld is th e u se o
lam in ar airf ow in join t prosth esis su rgery. Join t prosth esis
is a oreign m aterial an d oreign m aterials are pron e to at-
tach m en t o m icroorgan ism s [82]. Th e addition al ven tilation
w ith lam in ar f ow is believed to in crease th e rem oval o
bacteria arou n d th e su rgical eld. Th e lam in ar f ow sh ou ld
m ove particle- ree air over th e aseptic operatin g eld at
u n i orm velocity. Th e f ow can be delivered h orizon tally or
vertically. Horizon tal low is provided by w all-m ou n ted
distribu tion system s an d vertical f ow is provided by ceilin g-
m ou n ted distribu tion system s. Th e size o th e distribu tion
system s varies an d is u su ally larger th an 3.2 x 3.2 m [108].
Th e lam in ar airf ow acilities are u sed in th e m ajority o
operatin g room s u sed or orth opedic im plan t su rgery in
m an y cou n tries, su ch as Germ an y [109] an d New Zealan d
[1 10 ]. Several early stu dies [1 06 ] sh ow ed th at lam in ar air
f ow is ben e cial in redu cin g SSI rates. How ever, th is ob-
servation is ch allen ged in m ore recen t stu dies, or exam ple,
in a stu dy rom Bran dt [111]. Un til solid eviden ce is available,
orth opedic su rgery m ay be per orm ed in operatin g room s
w ith ou t lam in ar f ow . Th is statem en t is su pported by 85%
o orth opedic su rgeon s in a con sen su s [9]. Th e con sen su s
also stated th at applyin g lam in ar airf ow is a com plex tech -
n ology th at m u st u n ction in strict adh eren ce to m ain ten an ce
protocols.
In th e operatin g room , m an y in dividu als are presen t, in clu d-
in g th e su rgeon , an esth esiologist, su rgeon in train in g,
operatin g n u rses, an d som etim es stu den ts. Microorgan ism s
residin g on th e h air, skin , an d cloth es can be dispersed to
th e operatin g room en viron m en t, in clu din g to th e patien ts
[64]. Hu m an m ovem en t creates tu rbu len ce an d distu rbs th e
ven tilation o th e operatin g room . Th e dispersion can occu r
by sim ple m ovem en t or by talkin g [64 ]. A stu dy in 1975
sh ow ed th at th e bacterial cou n ts in creased rom 13 31
CFU/ squ are eet/ h ou r in an em pty operatin g room to 447.3
186.7 CFU/ squ are eet/ h ou r w h en ive people w ere
in trodu ced [67]. It is th ere ore im portan t to lim it th e n u m ber
o people in th e operatin g room to as ew as possible. Th e
m ore person n el in th e operatin g room th e h igh er th e n u m ber
o door open in gs [112] w h ich can in tu rn in crease SSIs [113].
It w as n oted in a stu dy th at on average th e door open in g in
prosth etic join t su rgery occu rred at th e rate o 0.7/ m in u te
in prim ary arth roplasty an d 0.8/ m in u te in revision arth ro-
plasty su rgery [113]. Open in g th e doors o operatin g room s
h as been sh ow n to in crease th e n u m ber o bacteria tw o old
[67]. An oth er problem th at can be cau sed by m u ltiple open -
in gs o th e doors is th e overu se o th e lam in ar airf ow lter
becau se o th e n eed to in crease th e air passin g th rou gh th e
lter in respon se to th e pressu re gradien t drop cau sed by
m u ltiple door open in gs. Min im izin g operatin g room door
open in g can be ach ieved sim ply by, or exam ple, u sin g th e
ph on e rath er th an con du ctin g discu ssion s in person .
3 .3 Us in g s t e rilize d in s t ru m e n t s
Su rgical in stru m en ts m akin g con tact w ith body tissu es or
f u ids are con sidered critical item s [52]. Th ese in stru m en ts
sh ou ld be sterile w h en u sed becau se in adequ ately sterilized
in stru m en ts m ay resu lt in disease tran sm ission [114]. Most
su rgical devices are m ade o h eat-stable m aterials an d can
th ere ore u n dergo pressu rized steam sterilization . Wh en th e
in stru m en ts are n ot h eat stable, low-tem peratu re sterilization
w ith , eg, eth ylen e oxide gas, h ydrogen peroxide gas plasm a,
peracetic acid im m ersion , an d ozon e can be u sed [5 2]. A
sterile in stru m en t is de n ed as a probability o th e presen ce
o m icroorgan ism s on th e in stru m en t a ter sterilization [52].
Th is probability is expressed as th e sterility assu ran ce level.
Th e sterility assu ran ce level or scalpels, or exam ple, is
arbitrarily set at 10 -6 [52]. Th e sterilized in stru m en ts are kept
in in stru m en t trays in th e operatin g room . It is recom m en d-
ed th at th e in stru m en t trays sh ou ld be open ed sh ortly be ore
th e start o th e su rgical procedu re. Th e con tam in ation rate
o th e trays in creases rom 4% a ter 30 m in u tes o open in g
to 30% 4 h ou rs a ter open in g [11 5]. Su rgical in stru m en ts
can also be f ash sterilized. Flash sterilization is per orm ed
on an u n w rapped object at 132 C or 3 m in u tes. It sh ou ld
be per orm ed on ly on su rgical in stru m en ts or im m ediate
u se, su ch as to sterilize an in adverten tly dropped in stru m en t
[3]. It sh ou ld be avoided an d n ot be don e or con ven ien ce
reason s.
53
 Se ct io n 1Principle s
4Pre ve ntion
of
intraope rative
infe ction
4 Po s t o p e ra t ive m e a s u re s
Appropriate postoperative care o th e su rgical w ou n d is
im portan t to preven t SSIs. Th e su rgical in cision th at is closed
prim arily is u su ally covered w ith a sterile dressin g or 2448
h ou rs [3 ]. Th ere is lim ited eviden ce on best practice as to
w h eth er an in cision m u st be covered by a dressin g an d
w h eth er th e patien t can sh ow er a ter 48 h ou rs [3]. In prac-
tice, th e su rgical w ou n d is o ten clean sed w ith sterile salin e
solu tion to rem ove w ou n d debris an d su rplu s o w ou n d
exu dates.
A su rgical in cision th at is le t open to h eal by secon dary
in ten tion can also be packed w ith sterile m oist gau ze an d
covered w ith a sterile dressin g [3]. Th ere are variou s types
o dressin g, w ith or w ith ou t topical solu tion s [11 6 , 1 17 ], bu t
th ere is n o eviden ce th at on e is better th an th e oth ers in
redu cin g SSI rates [11 8 ] as sh ow n by stu dies in volvin g gas-
troin testin al su rgeries [116118]. Argu ably, topical an tibiotics
can be u sed in a w ou n d th at is le t open to h eal by secon dary
in ten tion . Th e possible side e ects o th is action are an ti-
m icrobial resistan ce an d possible allergic reaction . An RCT
ailed to sh ow th e ben e cial e ect o application o topical
ch loram ph en icol on su rgical w ou n ds a ter h ip ractu res [119].
54
In th is stu dy, SSI rates at 30 days served as th e ou tcom e
m easu re. In practice, an tiseptics su ch as ch lorh exidin e an d
povidon e-iodin e are som etim es u sed in ch ron ic w ou n d care.
Th e dressin g o th e w ou n d th at is prim arily closed or w ou n d
th at is le t open or secon dary h ealin g sh ou ld be ch an ged
by u sin g eith er sterile or clean tech n iqu es. Both tech n iqu es
in volve m eticu lou s h an d w ash in g. In sterile tech n iqu e, a
sterile eld is created an d sterile gloves are u sed or applica-
tion o a sterile dressin g, w h ile in clean tech n iqu e, clean
gloves are u sed [120]. Th e sterile tech n iqu e is clearly m ore
expen sive th an th e clean tech n iqu e. Th e scien ti c basis
o sterile tech n iqu e is lackin g [118] bu t it is con sidered th e
gold stan dard an d recom m en ded by th e CDC [3].
Patien ts are o ten disch arged be ore in cision w ou n ds are
u lly h ealed. It is param ou n t to edu cate th e patien ts an d
th eir am ily m em ber(s) regardin g proper in cision care. Also,
th e patien ts an d th eir am ily m em ber(s) sh ou ld be edu -
cated to recogn ize an d report th e presen ce o sym ptom s o
SSI [3].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Erlangga Yusuf, Olivier Borens
5 An t ib io t ic p ro p h yla xis
5 .1 Th e b a s ics o f a n t im icro b ia l p ro p h yla xis
Su rgical an tim icrobial proph ylaxis is given to preven t SSIs.
Its ben e t in preven tin g SSIs h as been sh ow n as early as
th e 1980s, w h ere ce azolin proph ylaxis w as sh ow n to redu ce
th e n u m ber o prosth etic join t in ection s sign i can tly rom
3.3% (placebo) to 0.9% [12 1 ]. Th e practice o proph ylaxis
is a broadly accepted practice, especially in prosth etic join t
su rgery. Th e practice h as evolved regardin g th e tim in g an d
th e n u m ber o th e doses th at sh ou ld be given . In Germ an y,
proph ylaxis is given to 98% o patien ts h avin g h ip an d kn ee
replacem en ts [11 1 ]. Th e u se o su rgical an tibiotic proph y-
laxis can lead to adverse even ts, su ch as allergy, an tibiotic-
associated diarrh ea, an d an tim icrobial resistan ce. Bu t th ese
poten tial problem s are qu ite u n com m on . Th ere is very
lim ited data on oth er adverse even ts on su rgical an tibiotic
proph ylaxis an d in case o allergy, altern ative an tibiotics
can be u sed, as w ill be described below [122].
Th e ch oice o a proph ylactic an tibiotic depen ds on th e
m icroorgan ism s likely to cau se SSI in th e plan n ed su rgery.
Su rgical-site in ection s a ter orth opedic procedu res are
m ain ly cau sed by gram -positive bacteria, m ost requ en tly
S aureus. Th e an tibiotic u sed sh ou ld th ere ore cover th ese
m icroorgan ism s. Th e recom m en dation s an d ch aracteristics
o proph ylactic an tibiotics th at can be u sed in orth opedic
procedu res are sh ow n in Ta b le 4-3 . For practical reason s an d
du e to better bioavailability, an tibiotic proph ylaxis is ad-
m in istered in traven ou sly. Ce azolin or ce u roxim e are
recom m en ded by several gu idelin es, su ch as th e Am erican
Academ y o Orth opedic Su rgeon s [12 3 ] an d Scottish In ter-
collegiate Gu idelin es [122], to be u sed as th e rst ch oice or
an tibiotic proph ylaxis in orth opedic su rgeries. Ce azolin is
a rst-gen eration ceph alosporin active again st streptococci
an d m eth icillin -su sceptible S aureus. Ce u roxim e is a secon d-
gen eration ceph alosporin an d h as broader activity again st
Primary choice
Cefazolin Cefuroxime
Dose (intravenous) 12 g 1.5 g
Redosing interval in case of prolonged surgery 25 h 34 h
Renal half-life 1.252.5 h 12 h
Renal half-life in patients with end-stage renal disease 4070 h 1522 h
Infusion duration when dose is injected directly into vein or via 35 min 35 min
running intravenous fluids
Ta b le 4 -3 Re com m e ndations and characte ristics of prophylactic antibiotics that can be use d in orthope dic proce dure s, adapte d from Bratzle r,
e t al [139 ]. Dosing is base d on a 70 kg patie nt but dosing should be adjuste d base d on the body we ight in kilogram s (mg/ kg dosing).
Abbre viation: MRSA, m e thicillin-re sistant Sta phylococcus a ure us.
gram -n egative bacteria. Wh en patien ts presen t w ith pen icil-
lin allergy, it sh ou ld be determ in ed wh eth er an IgE-m ediated
respon se (an aph ylaxis) h as occu rred previou sly w h en
pen icillin w as adm in istered [9]. A u se u l m eth od to do th is
is by in qu irin g abou t th e tim e o occu rren ce o th e allergic
reaction . Reaction s startin g w ith in th e rst h ou r a ter ad-
m in istration are IgE m ediated. Am on g th e possible reaction s
are u rticaria, pru ritic rash , w h eezin g, an d dysph agia du e to
laryn geal edem a an d bron ch ospasm , h ypoten sion an d local
sw ellin g. It is estim ated th at th e rate o allergic reaction to
ceph alosporin s in patien ts w ith pen icillin allergy is 7% , an d
in n on pen icillin -allergic patien ts 1% [12 7 ]. A patien t w h o
experien ced an allergic reaction to a speci c ceph alosporin
sh ou ld perh aps n ot receive th at sam e ceph alosporin again ,
bu t a di eren t ceph alosporin m ay be u sed [126]. Th ere are
oth er altern ative proph ylactic an tibiotics w h ich can be u sed
w h en patien ts are allergic to -lactam an tibiotics su ch as
clin dam ycin (600900 m g in traven ou sly) or van com ycin
(1 g in traven ou sly). Rou tin e u se o van com ycin or su rgical-
site in ection proph ylaxis is n ot recom m en ded or an y type
o su rgery becau se its u se is associated w ith van com ycin -
resistan t Enterococcus colon ization an d in ection [9 , 1 2 9 ].
Patien ts allergic to -lactam an tibiotics sh ou ld receive
clin dam ycin as a rst ch oice. Van com ycin is a secon d ch oice
or th ose with kn own colon ization o MRSA an d with h igh er
risk or postoperative MRSA in ection , eg, patien ts w ith
recen t h ospitalization an d in stitu tion alized patien ts [9]. It is
im portan t to bear in m in d th at th e ch oice o an tibiotic
su rgical proph ylaxis sh ou ld also con sider th e local epide-
m iology. For exam ple, th e su sceptibilities o S aureus an d
Staphylococcus epidermidis to ce azolin in two academ ic h ospitals
in New York an d Ch icago in th e USA w ere on ly 74% an d
44% , respectively [130].
Th e above-m en tion ed su rgical proph ylaxis gu idelin es apply
to clean an d clean -con tam in ated elective an d em ergen cy
su rgeries. Wh en con tam in ation is already presen t be ore
Alternative
Clindamycin (in case of -lactam allergies) Vancomycin (in case of -lactam
allergies and MRSAduring screening)
600900 mg 1g
36 h 612 h
25.1 h 3.55.0 h
3.55.0 h 44.1406.4 h
1060 min 60 min
55
 Se ct io n 1Principle s
4Pre ve ntion
of
intraope rative
infe ction
su rgery, or exam ple, in open ractu res, oth er an tibiotics
sh ou ld be given as treatm en t sin ce gram -positive an d gram -
n egative bacteria are ou n d in open ractu re w ou n ds [131].
Th is n din g su ggests th at in open ractu res addition al gram -
n egative coverage sh ou ld be added [132]. To th is en d, variou s
regim en s h ave been u sed an d proposed, su ch as am oxicillin /
clavu lan ic acid [13 1 ], a com bin ation o ceph alosporin s w ith
am in oglycosides [132], an d a com bin ation o ceph alosporin s
w ith qu in olon es [133].
5 .2 Wh e n a n d fo r h o w lo n g t o a d m in is t e r
p ro p h yla ct ic a n t ib io t ics
An tim icrobial proph ylaxis sh ou ld be given so th at seru m
an d tissu e dru g levels are ach ieved or th e du ration o th e
operation . Seru m levels sh ou ld be h igh er th an th e m in im u m
in h ibitory con cen tration o th e m icroorgan ism s possibly
en cou n tered du rin g th e su rgery. Min im u m in h ibitory
con cen tration is th e low est an tibiotic con cen tration th at
in h ibits th e grow th o bacteria. In 1961, it w as sh ow n th at
w h en an tibiotics w ere given be ore in cision S aureus cou ld
be su ppressed [13 4 ]. Abou t 30 years later an RCT w as per-
orm ed on th e rate o SSI in th e preoperative ph ase (adm in -
istration o an tibiotics 2 h ou rs be ore th e su rgical in cision ),
th e early ph ase (224 h ou rs be ore th e su rgical in cision ),
th e in traoperative ph ase (w ith in th e 3 h ou rs a ter th e in ci-
sion ), an d th e postoperative ph ase (m ore th an 3 bu t less
th an 24 h ou rs a ter th e in cision ) [135]. Th e patien ts in th is
stu dy u n derw en t elective-clean or clean -con tam in ated
su rgical procedu res. Th e com parison sh owed th at th e lowest
SSI rates occu rred w h en th e proph ylactic an tibiotic w as
given in th e preoperative ph ase (0.6% ), ollow ed by in tra-
operative (1.4% ), postoperative (3.3% ), an d early (3.8% )
ph ase adm in istration . A m ore recen t stu dy rom Sw itzerlan d
elaborated u rth er on th e tim in g o proph ylactic an tibiotic
adm in istration an d ou n d th at adm in istration o ce u roxim e
3059 m in u tes be ore in cision is m ore e ective th an du rin g
56
th e last 30 m in u tes [136]. Th e SSI rate w as h igh er w h en th e
an tibiotic w as given w ith in 30 m in u tes o in cision th an be-
tw een 31 an d 60 m in u tes, h ow ever, th is di eren ce w as n ot
statistically sign i can t [137 ]. Th e con sen su s is th u s to ad-
m in ister an tibiotics w ith in 1 h ou r prior to su rgical in cision .
Th is m ay be exten ded to 2 h ou rs or van com ycin .
A stu dy rom Germ an y listed th e com m on m istakes in ad-
m in istration o an tibiotic proph ylaxis an d th e tim in g o
adm in istration is o ten m en tion ed. In som e cases, an tibiotics
w ere given too early or too late a ter th e skin in cision h ad
been m ade [138].
An tibiotic proph ylaxis u su ally in volves ju st a sin gle dose
preoperatively. In situ ation s o sign i can t blood loss (m ore
th an 1.5 L) an d len gth y operation s (beyon d 3 h ou rs), an ti-
biotics sh ou ld be redosed at in tervals o 12 tim es h al -li e
o th e an tibiotics. As proph ylaxis, ce azolin an d ce u roxim e
can be redosed every 35 h ou rs, clin dam ycin every 36
h ou rs, an d van com ycin every 612 h ou rs ( Ta b le 4 -3 ) [139].
Proph ylactic an tibiotics sh ou ld n ot be u sed lon ger th an a
24-h ou r du ration .
5 .3 Pro p h yla ct ic a n t ib io t ics in s p e cia l ca s e s
As m en tion ed previou sly, patien ts w ith asym ptom atic bac-
teriu ria plan n ed to u n dergo orth opedic su rgery do n ot n eed
to be treated w ith an tibiotics. On ly patien ts presen tin g w ith
sym ptom s o u rin ary tract in ection n eed to be treated
prior to elective arth roplasty [9].
In patien ts w h o h ave im plan ts su ch as h eart valves, th e
sam e proph ylactic an tibiotics as in patien ts w ith ou t earlier
im plan ted prosth eses can be u sed [9 ]. In dividu als w ith
prosth etic h eart valves h ave a h igh er risk or en docarditis.
En docarditis an d prosth etic join t in ection are both m ost
o ten cau sed by S aureus an d S epidermidis [140].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Erlangga Yusuf, Olivier Borens

6 Co n clu s io n

Su rgical-site in ection preven tion h as been stu died or m ore

th an 150 years a ter bein g pion eered by great sch olars, su ch
as Lou is Pasteu r, Ign az Sem m elw eis, Joseph Lister, an d
Alexan der Flem in g. We h ave review ed h ere th e best prac-
tices to preven t SSIs, su ch as m odi yin g patien t-related risk
actors an d takin g appropriate preoperative, in traoperative,
an d postoperative m easu res.

Th e preven tive m easu res described in th is ch apter can be

com bin ed in to a care bu n dle. A care bu n dle is de n ed by
In stitu te or Health care Im provem en t [141] as a stru ctu red
w ay o im provin g th e processes o care an d patien t ou tcom es
by u sin g a sm all, straigh t orw ard set o eviden ce-based
practices (gen erally th ree to ve). Su rgical-site in ection
rates are o ten u sed as h ospital qu ality m easu res [142] an d
im plem en tation o bu n dle elem en ts: in traoperative n orm o-
th erm ia, appropriate h air rem oval be ore su rgery, th e u se
o in traoperative an tibiotic proph ylaxis, an d disciplin e in
th e operation room h ave been sh ow n to redu ce SSIs by u p
to 51% in vascu lar procedu res [143]. Su ch a bu n dle can also
be im plem en ted in orth opedic su rgeries sin ce m an y evi-
den ce-based m easu res are readily available. Addition al stu dy
is requ ired w h ere scien ti c proo is lim ited to con tribu te
m ore kn ow ledge on th e m easu res preven tin g SSIs.

57
 Se ct io n 1Principle s
4Pre ve ntion
of
intraope rative
infe ction
7 Re fe re n ce s
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61
 Se ct io n 1Principle s
4Pre ve ntion
of
intraope rative
infe ction

62 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

We rner Zimme rli, Parham Se ndi
5 Sys te m ic a n tib io tics
We rn e r Zim m e rli, Parh am Se n d i
1 Ba s ics
Th e in trodu ction o an tim icrobial dru gs h as been on e o th e
biggest su ccess stories in clin ical m edicin e. Staphylococcus
aureus sepsis or bacterial m en in gitis, w h ich led to a leth al
ou tcom e in m ore th an 50% o th e patien ts, becam e treatable,
an d m ortality dropped to less th an 20% w ith appropriate
an tim icrobial th erapy [1, 2]. In th e eld o bon e an d join t
in ection s, su rgical treatm en t alon e, besides am pu tation s,
can n ot com pletely elim in ate m icroorgan ism s [36]. In th e
prean tibiotic era, arth rodesis w as o ten requ ired a ter staph -
ylococcal arth ritis. Sim ilarly, a ter open ractu re, ch ron ic
osteom yelitis was com m on place. Su ch in ection s o ten requ ired
dozen s o su rgical in terven tion s over several decades [7 ].
Likew ise, an tibiotic th erapy alon e is in su cien t or cu rin g
im plan t-associated bon e an d join t in ection s [8 , 9 ]. As an
exception , th erapeu tic su rgery is gen erally n ot requ ired in
patien ts with acu te h em atogen ou s osteom yelitis n ot in volvin g
im plan ts, as lon g as an tibiotic th erapy is rapidly started [10].
For an optim al ou tcom e, m ost bon e an d join t in ection s are
best m an aged by a team o di eren t specialists (see part 5
o th is ch apter). In com parison to h istorical care, loss o join t
u n ction an d ch ron ic osteom yelitis h ave becom e u n com m on
w ith adequ ate m an agem en t. More th an 80% o patien ts
w ith osteom yelitis or periprosth etic join t in ection can n ow
be cu red w ith th e rst treatm en t attem pt i th e correct m u l-
tidisciplin ary approach is ch osen [8, 11, 12].
Du rin g th e last decade, th e postan tibiotic era h as been
repeatedly h eralded [1 3]. Th e reason or th is u n ortu n ate
evolu tion is th e m isu se o an tim icrobial agen ts. Th e m ost
com m on m iscon ception is th e idea th at givin g an tibiotics
m ore requ en tly an d/ or or a lon ger tim e decreases th e risk
or in ection . An oth er error is treatm en t w ith an tibiotics
alon e in a case actu ally requ irin g su rgery. Th e act is th at
prolon ged an tibiotic proph ylaxis does n ot decrease th e rate
o in ection in an y type o su rgery, an d treatm en t w ith ou t
su rgery in creases th e risk or ch ron ic persisten ce o th e bio-
lm [1 2 , 1 4 ]. In addition , i a ebrile patien t gets em piric
an tibiotics w ith ou t su erin g rom a bacterial in ection , th e
ch an ge o h is/ h er m icrobiom e en dan gers h im / h er or an
in ection w ith m ore resistan t m icroorgan ism s [15]. Th ere ore,
th e correct u se o an tibiotics sh ou ld be u n derstood w ell by
all ph ysician s. In con trast to oth er dru gs su ch as an tih yper-
ten sive agen ts, th e liberal u se o an tibiotics h as an u n avorable
im pact on u tu re patien ts, ie, it m ay decrease th e su scepti-
bility o bacteria in a w h ole popu lation [1 6 , 1 7 ]. Th is is
illu strated by di eren t rates o m u ltiresistan t bacteria in
di eren t geograph ical areas w ith di eren t an tibiotic pre-
scribin g pattern s. Th ere ore, an tibiotic stew ardsh ip h as
becom e an im portan t task or th e in ectiou s diseases special-
ist, w h o sh ou ld n ot on ly con sider th e in ectiou s problem o
th e in dividu al patien t bu t also th e epidem iological situ ation
or u tu re patien ts.
63
 Se ct io n 1Principle s
5
Systemic
antibiotics
Th e appropriate u se o an an tim icrobial agen t depen ds on
th e type o in ection , th e species, an d su sceptibility o th e
m icroorgan ism . I an in ection is di cu lt to diagn ose, an
experien ced m icrobiologist sh ou ld be con su lted prior to th e
in terven tion . Th is allow s adequ ate sam plin g an d appropri-
ate iden ti cation procedu res. Correct iden ti cation an d
kn owledge o th e su sceptibility pattern allows an tim icrobial
th erapy w ith th e optim al dru g.
Th e ch oice o an an tim icrobial agen t sh ou ld con sider both
special properties o th e m icroorgan ism an d th e h ost. Th e
issu e o an tibiotics an d special properties o th e m icroorgan ism
are discu ssed below (see parts 2 an d 3 o th is ch apter). Host
actors sh ou ld also be con sidered w h en treatin g patien ts
w ith an tibiotics. Th ese in clu de previou s an tim icrobial th er-
apy, recen t h ospitalization or travels to region s w ith a h igh
prevalen ce o m u ltiresistan t m icroorgan ism s [18 , 1 9]. Th ese
patien ts poten tially h ave an altered skin f ora, w h ich is a
risk actor or m ore di cu lt-to-treat su rgical-site in ection s
[1 5 ]. Th e im m u n ocom peten ce o th e h ost is also a cru cial
actor. In th e eld o bon e an d join t in ection , th is plays a
special role in patien ts w ith m align an t bon e tu m ors u n der-
goin g ch em oth erapy as w ell as bon e replacem en t by tu m or
prosth esis [20]. I th ese patien ts su er rom im plan t-associ-
ated in ection , lon g-term bactericidal th erapy is requ ired.
I com plete eradication o in ection is n ot possible, li elon g
an tibiotic su ppression is n eeded. It h as been sh ow n th at th e
presen ce o an im plan t leads to an im paired elim in ation o
even a low n u m ber o m icroorgan ism s du e to a local gran -
u locyte de ect [21, 22]. Th is is cau sed by so-called ru strated
ph agocytosis [2 2]. In addition , m icroorgan ism s orm in g a
bio lm are partially resistan t to in tact gran u locytes [23 ].
64
2 De fin it io n o f t h e u s e o f a n t ib io t ics
In order to u se an tim icrobial agen ts in a ration al w ay, th e
type o u se sh ou ld be de n ed be ore startin g treatm en t.
An tibiotic th erapy is o ten in appropriately prolon ged. Th is
error is based on th e m iscon ception th at in ection can be
preven ted by an tibiotics du rin g th e early postoperative
period. Un ortu n ately, th e opposite is tru e. Th e altered skin
m icrobiom e arou n d th e wou n d in creases th e risk or in ection
w ith a m u ltiresistan t m icroorgan ism [15].
Th e ollow in g term s an d de n ition s are com m on ly u sed.
2 .1 An t im icro b ia l p ro p h yla xis
Proph ylaxis m ean s th at th e an tibiotic is presen t in th e w ou n d
be ore appearan ce o m icroorgan ism s. Sin ce pen etration o
th e an tim icrobial dru g in tissu e requ ires tim e, application
at least 30 m in u tes be ore startin g su rgery is n eeded or
optim al e cacy o su rgical proph ylaxis [24, 25]. A sin gle dose
is gen erally en ou gh . Prolon gation o proph ylaxis beyon d
24 h ou rs h as n ever been sh ow n to decrease th e rate o
su rgical-site in ection [2628].
2 .2 Pre e m p t ive t h e ra p y
In preem ptive th erapy, th e an tibiotic pen etrates th e w ou n d
a ter th e m icroorgan ism s, bu t be ore th e establish m en t o
overt in ection . Th is situ ation is observed in patien ts w ith
open ractu re u n dergoin g in tern al xation w ith in a ew
h ou rs. A sh ort cou rse o an tibiotics, n ot lon ger th an a ew
days, is su ggested or preven tion o su rgical-site in ection
[2830].
2 .3 Em p iric t h e ra p y
Em piric th erapy is de n ed as adm in istration o an an tibiotic
in a patien t w ith sign s an d sym ptom s o a bacterial in ection
bu t w ith ou t iden ti cation o th e m icroorgan ism . Th is pro-
cedu re is also called an edu cated gu ess. Th is in dicates th at
th e treatin g ph ysician sh ou ld con sider th e type o in ection ,
epidem iology, an d th e probable resistan ce pattern o th e
m ost probable m icroorgan ism (s), w h en ch oosin g an an ti-
biotic. As a ru le, em piric th erapy sh ou ld be optim ized as
soon as th e m icroorgan ism an d its su sceptibility are kn ow n ,
w h ich gen erally requ ires n ot m ore th an a ew days.
2 .4 Ta rge t e d t h e ra p y
Targeted th erapy m ean s th at an tibiotics are ch osen accord-
in g to a kn ow n m icroorgan ism an d its con rm ed an tibiotic
su sceptibility. Th e len gth o th erapy an d th e tim e o tran sition
rom in traven ou s (IV) to oral th erapy depen d on th e type
o in ection .
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
We rner Zimme rli, Parham Se ndi
2 .5 Su p p re s s ive t h e ra p y
I bacterial elim in ation (m icrobiological cu re) is n ot a realistic
option , lon g-term an tibiotic treatm en t w ith an oral dru g
m ay su ppress sym ptom s o in ection [31 ]. In gen eral, th is
treatm en t is on ly palliative. How ever, periodic stoppin g o
su ppressive th erapy by an experien ced team at a prede n ed
poin t in tim e allow s iden ti cation o patien ts w h o do n ot
requ ire li elon g su ppression .
2 .6 Sp e cia l co n s id e ra t io n s re ga rd in g a n t im icro b ia l
t h e ra p y o f b o n e a n d jo in t in fe ct io n s , in clu d in g
p h a rm a co k in e t ics in b o n e
An tibiotic th erapy o septic n ative join t arth ritis is gen erally
n ot m ore dem an din g th an treatm en t o pn eu m on ia or
bacterem ia, becau se all an tibiotics h ave a good pen etration
in syn ovial tissu es [3 2 , 3 3 ]. Th ere ore, local th erapy is n ot
requ ired an d poten tially h arm u l du e to possible cartilage
dam age. How ever, rapid in itiation o an tibiotics as w ell as
prom pt an d o ten repetitive rem oval o pu ru len t syn ovial
m em bran es is im portan t. In con trast, osteom yelitis requ ires
a prolon ged an tim icrobial th erapy w ith th e h igh est doses
to preven t recu rren ce. As in each type o in ection , pen etra-
tion o th e an tibiotic to th e site o in ection is a prerequ isite
or th e elim in ation o m icrobes [34, 35]. Lim ited an tibiotic
pen etration in bon e an d sequ estra (ie, bon e ragm en ts devoid
o blood su pply) at th e site o in ection jeopardize treatm en t
su ccess. How ever, it is im portan t to stress th at su rgery is a
prerequ isite or th e su ccess o an tim icrobial treatm en t. Th ere-
ore, it is a clin ical com m on place th at pu s m u st be drain ed
or rem oved to cu re th e patien t (u bi pu s, ibi evacu a). Th ere
are several reason s or th is statem en t. Som e an tibiotics su ch
as -lactam s h ave a sign i can tly h igh er m in im al in h ibitory
con cen tration (MIC) w h en th e n u m ber o bacteria is in -
creased. Th is ph en om en on is called in ocu lu m e ect an d
plays a con siderable role i -lactam s are u sed. Sin ce m icro-
organ ism s are tested at a den sity o 10 5 colon y- orm in g u n its
(CFU) in vitro, su sceptibility m ay n ot predict th eir e ect on
an abscess w h ere th e bacterial den sity is at 10 6 10 8 CFU [36].
Pu s n ot on ly con tain s a h igh n u m ber o bacteria, bu t also
n u m erou s gran u locytes eith er still active w ith in gested
bacteria, or apoptotic or n ecrotic.
Bon y pen etration am on g di eren t grou ps o an tim icrobial
agen ts is variable. How ever, an tibiotic con cen tration in bon e
can n ot be sim ply extrapolated to e cacy o treatm en t or
variou s reason s. Firstly, u su ally on ly a sin gle dose is given ,
w h ich does n ot ref ect equ ilibriu m . Secon dly, th e dru g con -
cen tration is m easu red in sterile bon e, w h ich is di eren t
rom th e clin ical situ ation . Th irdly, variou s tim e in tervals
betw een dru g application an d h arvestin g are u sed, resu ltin g
in n on com parable bon e or seru m con cen tration s. Fou rth ly,
variable tech n iqu es o sam ple preparation are u sed. Fin ally,
variable dru g determ in ation m eth ods (HPLC, bioassay, etc)
preclu de direct com parison o resu lts rom di eren t stu dies.
How ever, th e ollow in g statem en ts can be m ade or clin ical
practice. Flu oroqu in olon es, clin dam ycin , lin ezolid, an d ri-
am pin h ave good bon e pen etration w ith bon e or seru m
con cen tration ratios betw een 0.31.1. Pen icillin derivatives
an d ceph alosporin s h ave a low er pen etration ratio o on ly
0.10.3, an d 0.10.5, respectively [34].
2 .7 Tre a t m e n t s t u d ie s
Un ortu n ately, good clin ical stu dies on th e role o de n ed
an tibiotics in bon e an d join t in ection are scarce. En d-o -
treatm en t an alysis (eg, a ter 3 m on th s) is m ean in gless,
becau se cu re can n ot yet be de n itively ju dged at th is tim e.
A m in im u m ollow -u p o 1 year an d 2 years, respectively,
or bon e an d im plan t-associated in ection is requ ired. In
addition , con com itan t-adequ ate su rgical m an agem en t is as
im portan t as an tim icrobial th erapy in ch ron ic osteom yelitis
an d periprosth etic join t in ection . In th e m etaan alysis by
Sten gel et al [37 ], on ly 22 o 167 stu dies w ere eligible or
prim ary ou tcom e. Th ey ou n d n o di eren ce betw een di -
eren t an tibiotic grou ps, except or ri am pin , w h ich h as
sh ow n a h igh er clin ical su ccess rate in im plan t-associated
in ection th an it did in con trol treatm en t [38]. Sin ce treatm en t
o bon e an d join t in ection can n ot be based on con trolled
trials, th e lack o eviden ce h as been replaced by expert opin -
ion s [39 ]. In deed, th ere are several gu idelin es dealin g w ith
bon e an d join t in ection . Th e In ectiou s Diseases Society o
Am erica (IDSA) pu blish ed gu idelin es on th e m an agem en t
o diabetic oot in ection [40 ], periprosth etic join t in ection
[41], an d vertebral osteom yelitis [42].
65
 Se ct io n 1Principle s
5
Systemic
antibiotics
3 Wh a t t o d o if t h e re is a fa ilu re ?
I treatm en t ails, possible su rgical an d m edical reason s or
ailu re m u st both be evalu ated. Adh eren ce to recom m en ded
su rgical treatm en t con cepts sh ou ld be assessed. Su rgical
m an agem en t o di eren t types o bon e an d join t in ection s
is described in ch apters 8 Open ractu res, 9.1 In ection a ter
ractu re, 9.2 In ected n on u n ion , 10 In ection a ter join t
arth roplasty, 11.1 Septic arth ritis, 11.2 Septic arth ritis a ter
an terior cru ciate ligam en t su rgery, an d 12 Spon dylodiscitis.
Th e possibility o a secon dary in ection (also called su per-
in ection ) m u st also be con sidered. From th e perspective o
an in ectiou s diseases specialist, it is cru cial to rean alyze th e
organ ism (s) cau sin g th e ailu re or its an tim icrobial su scep-
tibility, an d th e poten tial reason s or em ergen ce o resistan ce.
Medical reason s or ailu re in clu de in adequ ate an tim icrobial
treatm en t du rin g th e rst episode, n on com plian ce o th e
patien t, dru g-dru g in teraction s, redu ced absorption o orally
adm in istered an tibiotics (eg, du e to dru g-dru g in teraction
in th e gastroin testin al tract), an d in con sisten t u se becau se
o u n derreported adverse even ts an d in toleran ce o th e dru g.
3 .1 Micro b io lo gica l re a s o n s fo r fa ilu re
Gen erally, su sceptible m icroorgan ism s do n ot becom e re-
sistan t du rin g th erapy. How ever, th ere are a ew exception s,
su ch as staph ylococci, w h ich can develop resistan ce by m u -
tation again st f u oroqu in olon es, ri am pin , or u sidic acid
[4345]. Sim ilarly, by selection o a resistan t su bpopu lation ,
Pseudomonas aeruginosa can becom e resistan t to an y kn ow n
an tibiotic du rin g th erapy [46, 47]. Th e risk or em ergen ce o
resistan ce is h igh est w h en th e bacterial load is h igh or a
bio lm persists. Adh eren t bacteria orm in g a bio lm can n ot
be elim in ated w ith an tibiotics exclu sively, su ch as -lactam s.
Characteristic Example
Intracellular persistence of Mycobacteria, Legionella species, Neisseria
microorganism species, S aureus, S pneumonia
Small-colony variants S aureus, Escherichia coli, etc.
Biofilm formation Presence of an implant or bony sequestrum
High bacterial density Abscess (inoculum effect)
Emergence of resistance during therapy Staphylococci to fluoroquinolones, rifampin;
P aeruginosa to fluoroquinolones
Ta b le 5 -1 Prope rtie s of m icroorganism s in ue ncing the ir
e lim ination by antim icrobial age nts.
Abbre viations: S aureus, Staphylococcus aureus; S pneumonia, Streptococcus
pneumonia; P aeruginosa, Pseudomonas aeruginosa.
66
Oth er actors leadin g to persisten ce o bacteria in th e h ost
are su m m arized in Ta b le 5 -1 . For exam ple, i in tracellu lar
bacteria are treated w ith an tibiotics, w h ich are n ot able to
pen etrate in to th e cell, treatm en t gen erally ails [4 8 , 4 9 ].
Som e m icroorgan ism s are obligatorily in tracellu lar, oth ers
su ch as S aureus or Streptococcus pneumonia are localized in tra-
an d extracellu larly. Sm all-colon y varian ts o bacteria typi-
cally su rvive an tim icrobial th erapy becau se th is ph en otype
is resistan t to m an y an tibiotics, an d becau se it is able to
persist in n on pro ession al ph agocytes, su ch as broblasts
[50, 51]. In tracellu lar m icroorgan ism s are protected again st
-lactam s or am in oglycosides [48 ].
3 .2 Me d ica l re a s o n s fo r fa ilu re in a d e q u a t e
a n t im icro b ia l t re a t m e n t
Th e prin ciples o appropriate an tim icrobial treatm en t are
described above (see part 2 o th is ch apter), an d th e speci c
ch oice o an tibiotics elsewh ere [8]. Despite ch oosin g th e correct
com pou n d, th e tim in g o its adm in istration m ay be in ade-
qu ate. For exam ple, ri am pin resistan ce o staph ylococci
m ay em erge i adm in istered be ore debridem en t su rgery,
ie, at a tim e w h en th ere is still a h igh bacterial load [52 ].
Th u s, i treatm en t o staph ylococcal in ection ails in a patien t
previou sly exposed to ri am pin , th orou gh su sceptibility test-
in g is essen tial or th e evalu ation o u rth er treatm en t op-
tion s. Flu oroqu in olon es are n ot su cien tly e ective in an
acid en viron m en t (eg, large am ou n t o pu s) [53]. Sim ilarly,
am in oglycosides are bou n d an d in activated by ree DNA,
w h ich is abu n dan t in th e abscess f u id [5 4]. In in ection s
cau sed by gram -n egative bacteria, it is im portan t to recog-
n ize m icroorgan ism s displayin g a alse su sceptibility resu lt
in vitro, eg, Enterobacter species. Alth ou gh ph en otypically
su sceptible to th ird-gen eration ceph alosporin s, th ese path o-
gen s are gen otypically resistan t, eg, Am pC produ cers [55].
In oth er w ords, or som e bacteria th e su sceptibility pattern
in vitro does n ot reliably predict th e treatm en t su ccess in
vivo. Th ere ore, good collaboration w ith a specialized m i-
crobiological laboratory m u st be in itiated in th ese cases, in
particu lar, in th e even t o treatm en t ailu re.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
We rner Zimme rli, Parham Se ndi
3 .3 Me d ica l re a s o n s fo r fa ilu re n o n co m p lia n ce o f
t h e p a t ie n t
In som e cases, th e im portan ce o dru g adh eren ce is n ot
obviou s to th e patien t or social, m en tal, econ om ic, or in tel-
lectu al reason s. In addition , th e possibility o adverse even ts
or in toleran ce w ith ou t obviou s side e ects m u st be actively
evalu ated (see part 3.6 in th is ch apter). I poor dru g adh er-
en ce is n ot rapidly recogn ized by th e respon sible ph ysician ,
treatm en t ailu re m ay occu r. In th ese cases, directly observed
treatm en t or ou tpatien t IV treatm en t are im portan t option s.
3 .4 Me d ica l re a s o n s fo r fa ilu re d ru g-d ru g
in t e ra ct io n s
Most patien ts w ith an osteoarticu lar in ection h ave several
com orbidities, an d h en ce m u st be treated w ith oth er m ed-
ication s in addition to an tibiotics. Th ere ore, dru g-dru g
in teraction s m u st be evalu ated prior to prescribin g an tim i-
crobial treatm en t. In addition , each n ew dru g, w h ich is
added in a patien t already takin g an tibiotics, m u st be ch ecked
or possible in teraction . Im portan tly, th e possibility th at th e
patien ts com edication redu ces th e seru m con cen tration s o
th e an tibiotics m u st be evalu ated. Con sideration m u st be
given to su bstan ces th at m ay redu ce th e absorption o orally
adm in istered an tibiotics. Ta b le 5-2 provides an overview o
com m on ly adm in istered com pou n ds in osteoarticu lar in ec-
tion s an d o su bstan ces th at can poten tially redu ce th eir
seru m con cen tration s.
3 .5 Me d ica l re a s o n s fo r fa ilu re re d u ce d a b s o rp t io n
o f o ra lly a d m in is t e re d a n t ib io t ics
An tacids, ood (eg, m ilk produ cts), an d ch elators (eg, su b-
stan ces con tain in g iron , calciu m or m agn esiu m ) decrease
th e absorption o several an tibiotics ( Ta b le 5-2 ). Th e patien ts
h istory m u st be care u lly evalu ated in th is respect, becau se
m an y patien ts do n ot con sider su pplem en ts, su ch as m ag-
n esiu m or calciu m , as tru e dru gs. Th e clin ical relevan ce o
a redu ced seru m con cen tration o an tibiotics is di cu lt to
estim ate in a broad popu lation , bu t cases o treatm en t
ailu re h ave been observed [56, 57]. Con sequ en tly, th e in take
o th ese su pplem en ts sh ou ld be evalu ated an d adequ ately
sch edu led (eg, 1 h ou r be ore or 2 h ou rs a ter in take o an -
oth er dru g or m eal). Cou n selin g o th e patien t an d am ily
by a h ospital-based ph arm acist prior to disch arge can be
u se u l.
3 .6 Me d ica l re a s o n s fo r fa ilu re in t o le ra n ce o f
a n t ib io t ics
Adverse even ts an d in toleran ce w ith ou t obviou s m easu rable
dru g toxicity m u st be evalu ated du rin g th e ollow -u p o
patien ts treated w ith an tibiotics. Nau sea an d vom itin g m u st
be rapidly recogn ized an d adequ ately m an aged. I adm in -
istration o an tiem etics is n ot h elp u l, altern ative treatm en t
option s sh ou ld be evalu ated. In case o ri am pin treatm en t
o im plan t-associated staph ylococcal in ection , h ow ever,
m ain ten an ce o ri am pin th erapy is im portan t. Th e au th ors
recom m en d 450 m g tw ice daily on an em pty stom ach w ith
a glass o w ater, pre eren tially 1 h ou r prior to m eals or 2
h ou rs a ter. Oth ers h ave recom m en ded 900 m g daily, 600
m g daily, or 300 m g tw ice daily (review ed in [39]). In th e
au th ors experien ce, 900 m g is o ten n ot w ell tolerated. I
450 m g tw ice daily cau ses n au sea or vom itin g, in take w ith
m eals is a rst step. I sym ptom s persist, a dose redu ction
to 300 m g tw ice daily is th e secon d step.
67
 Se ct io n 1Principle s
5
Systemic
antibiotics

Agent Other drug antibiotic* Antibiotic other drug Avoid combination Intake Proposed Common side
with mechanism e ects|| /
Antibiotic serum Antibiotic serum May serum May serum
or reduced Comments
concentration concentration concentration o concentration o
absorption
by by
Penicillin, Probenecid, Chloroquine,# Methotrexate, Mycophenolate, Bacteriostatic acting Without Acid liability Diarrhea,
amoxicillin, salicylate, lanthanum# vitamin K hormonal antimicrobial agents, food hypersensitivity
ampicillin, indometacin, antagonists, contraceptives, eg, tetracycline reaction
amoxicillin/ sulfinpyrazon digoxin,# atenolol# derivates Only for selected
clavulanic acid allopurinol** OAI cases after
sufficiently long IV
treatment
Ciprofloxacin, Metoclopramide Cations (eg, Inhibition of ---- Cations, Without Chelation Nausea, diarrhea,
levofloxacin (faster resorption) aluminium, isoenzymes of antiarrhythmic drugs milk fatigue, neurotoxicity,
calcium, iron, cytochrome P450 of class IAor III (QT products tendinopathy,
magnesium), 1A2 and 3A4 time prolongation) arthralgia
antacids (eg, Sildenafil, vitamin
omeprazole) Kantagonists,
methotrexate
Rifampin Probenecid, Antacids, opium ---- Strong induction Compounds Without Food increases Nausea, vomitus,
cotrimoxazole.*** derivates, of isoenzymes of enhancing side food first-pass abdominal
anticholinergic cytochrome P450, effects metabolism pain, elevation
compounds, vitamin K of liver values,
ketoconazole antagonists, hypersensitivity
hormonal reaction, vasculitis
contraceptives
Doxycycline, ---- Cations (eg, Vitamin K Hormonal Methoxyflurane Without Chelation Nausea, phototoxicity
minocycline aluminium, antagonists, contraceptives milk
calcium, iron, methotrexate, products
magnesium), cyclosporine
antacids, rifampin,
alcohol

Ta b le 5 -2 Oral form ulations of antim icrobial age nts comm only use d in oste oarticular infe ctions, and com pounds in ue ncing the ir e nte ral
absorption and/ or se rum conce ntration. The list is not e xhaustive .
Abbre viations: OAI, oste oarticular infe ction; HIV, human im m unode cie ncy virus.
*
Othe r drugs in ue ncing the se rum conce ntration or e ffe cts of antim icrobial age nt or its m e tabolite s.

Antim icrobial age nt in ue ncing the se rum conce ntration or e ffe cts of othe r drugs or its m e tabolite s.

Avoid live vaccine s susce ptible to antibiotics (e g, typhoid vaccine , Bacille de Calm e tte e t Gu rin [BCG]). The consultation of a
pharmacologists or com pute r-base d drug inte raction program is always re com m e nde d. All com binations that point towards incre ase d
se rum le ve ls, e nhance d side e ffe cts, or toxicity of one or the othe r drug must be close ly m onitore d or avoide d.

Pre fe rre d die tary re com m e ndations.
||
All antibiotics can cause diarrhe a. In case of diarrhe a, re sorption of antibiotics may be im paire d. Only com m on side e ffe cts are liste d. For
m ore de tail consult your local pharm acopoe ia.

Mainly de scribe d for pe nicillin.
#
Mainly de scribe d with com pounds containing am picillin and am oxicillin.
**
May e nhance the pote ntial for hype rse nsitivity re actions to am picillin and am oxicillin.

The authors re com m e nd the se against oste oarticular infe ctions due to bacte ria with low-pe nicillin m inim al-inhibition conce ntration
(e g, Priopioniba cte rium a cne s, -he m olytic stre ptococci or am oxicillin for am oxicillin-susce ptible e nte rococci), and if the patie nt has no
e vide nce of im paire d e nte ral absorption. The bioavailability of am oxicillin and am picillin are highe r and m ore pre dictable than the one for
pe nicillin V.

Due to the large varie ty of possible inte ractions, the consultation of a pharm acologist or com pute r-base d drug inte raction program is
strongly re com m e nde d.
***
The clinical signi cance of this inte raction in the tre atm e nt of oste oarticular infe ctions is unknown. Monitor tre atm e nt succe ss and pote ntial
side e ffe cts of the drug.
Information from re fe re nce s [6 5 6 7 ].

68 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

We rner Zimme rli, Parham Se ndi

Agent Other drug antibiotic* Antibiotic other drug Avoid combination Intake Proposed Common side
with mechanism e ects|| /
Antibiotic serum Antibiotic serum May serum May serum
or reduced Comments
concentration concentration concentration o concentration o
absorption
by by
Fusidic acid Statins, ritonavir ---- Vitamin K ---- HIVprotease ---- ---- Nausea, fatigue
antagonists, inhibitors,
statins, ritonavir, statins
cyclosporine
Cotrimoxazole Indomethacin Rifampin*** Digoxin, phenytoin, Tricyclic Dofetilid, After a ---- Hypersensitivity
methotrexate, antidepressants, compounds meal reaction,
dofetilid hormonal enhancing side hematotoxicity,
contraceptives effects (eg, linezolid increased creatinine,
and hematotoxicity) hyperkalemia

Linezolid ---- ---- Sympathomimetics, ---- Compounds ---- ---- Hyperglycemia,

vasopressors, enhancing adverse headache, diarrhea,
dopaminergic events (eg, vomitus, nausea,
compounds, cotrimoxazole and elevated liver
serotonin-uptake hematotoxicity) values, reversible
inhibitors hematotoxicity,
irreversible
neurotoxicity
Clindamycin ---- ---- Neuromuscular ---- Erythromycin ---- ---- Nausea, vomitus,
blocking agents (antagonisms) diarrhea
Metronidazole Cimetidine Phenobarbital, Alcohol, ---- Busulfan ---- ---- Nausea, abdominal
phenytoin vitamin K pain, headache,
antagonists, rarely neurotoxicity
disulfiram, lithium,
cyclosporine
5-fluoruracil,
busulfan

Ta b le 5 -2 Oral form ulations of antim icrobial age nts comm only use d in oste oarticular infe ctions, and com pounds in ue ncing the ir e nte ral
absorption and/ or se rum conce ntration. The list is not e xhaustive . (cont).
Abbre viations: OAI, oste oarticular infe ction; HIV, human im m unode cie ncy virus.
*
Othe r drugs in ue ncing the se rum conce ntration or e ffe cts of antim icrobial age nt or its m e tabolite s.

Antim icrobial age nt in ue ncing the se rum conce ntration or e ffe cts of othe r drugs or its m e tabolite s.

Avoid live vaccine s susce ptible to antibiotics (e g, typhoid vaccine , Bacille de Calm e tte e t Gu rin [BCG]). The consultation of a
pharmacologists or com pute r-base d drug inte raction program is always re com m e nde d. All com binations that point towards incre ase d
se rum le ve ls, e nhance d side e ffe cts, or toxicity of one or the othe r drug must be close ly m onitore d or avoide d.

Pre fe rre d die tary re com m e ndations.

||
All antibiotics can cause diarrhe a. In case of diarrhe a, re sorption of antibiotics may be im paire d. Only com m on side e ffe cts are liste d. For
m ore de tail consult your local pharm acopoe ia.

Mainly de scribe d for pe nicillin.

#
Mainly de scribe d with com pounds containing am picillin and am oxicillin.
**
May e nhance the pote ntial for hype rse nsitivity re actions to am picillin and am oxicillin.

The authors re com m e nd the se against oste oarticular infe ctions due to bacte ria with low-pe nicillin m inim al-inhibition conce ntration
(e g, Priopioniba cte rium a cne s, -he m olytic stre ptococci or am oxicillin for am oxicillin-susce ptible e nte rococci), and if the patie nt has no
e vide nce of im paire d e nte ral absorption. The bioavailability of am oxicillin and am picillin are highe r and m ore pre dictable than the one for
pe nicillin V.

Due to the large varie ty of possible inte ractions, the consultation of a pharm acologist or com pute r-base d drug inte raction program is
strongly re com m e nde d.
***
The clinical signi cance of this inte raction in the tre atm e nt of oste oarticular infe ctions is unknown. Monitor tre atm e nt succe ss and pote ntial
side e ffe cts of the drug.
Information from re fe re nce s [6 5 6 7 ].

69
 Se ct io n 1Principle s
5
Systemic
antibiotics

Mechanisms o action and comments

Class: -lactams Growth inhibition by inactivating enzymes located in the bacterial cell membrane, which are involved in cell wall synthesis. They are generally
bactericidal.
Compounds Spectrum Dose * Comment
Penicillin G Propionibacterium acnes, streptococci, 35 million units every 46 hr The authors recommend determining MIC
staphylococci (penicillin-susceptible) prior to treatment
Amoxicillin (Europe) See Penicillin G, 2 g every 4 to 6 hr Typically used for targeted therapy: OAI due
Ampicillin (USA) Enterococcus species (amoxicillin-susceptible) 2 g every 4 hr to Enterococcus species
Amoxicillin / clavulante (Europe) Staphylococci (oxacillin-susceptible), streptococci, 2.2 g every 6 hr Commonly used as empiric therapy in
Ampicillin / sulbactam (USA) anaerobes, Enterococcus species (amoxicillin- regions with low prevalence of MRSAand
susceptible), Haemophilus influenzae, 3 g every 6 hr ESBL-producing enterobacteriaceae
susceptible enteroacteriaceae
Flucloxacillin (Europe) Staphylococci (oxacillin-susceptible) 2 g every 6 hr Targeted therapy with narrow staphylococcal
Nafcillin (USA) 1.5 to 2 g every 4 to 6 hr spectrum
Cefazolin Staphylococci (oxacillin-susceptible), streptococci 1.5 to 2 g every 6 hr Treatment option in case of cutaneous
hypersensitivity reaction to penicillin
derivates
Ceftriaxone Streptococci, Haemophilus influenzae, 2 g every 24 hr Target therapy often used for outpatient IV
susceptible enterobacteriaceae treatment
Ceftazidime See ceftriaxone 2 g every 8 hr
Cefepime See ceftazidime, higher in vitro activity against 2 g every 8 hr For the treatment of Enterobacter species,
staphylococci (oxacillin-susceptible), streptococci, the authors recommend determining MIC.
and Enterobacter species Monitor neurotoxicity, in particular in patients
with impaired renal function.
Class: Carbapenems Have a -lactam ring (potential for allergic cross-reactivity). Carbapenems are generally resistant to cleavage by most plasmid and
chromosomal -lactamases. Given their broad spectrum, their use should be strictly limited both to duration of therapy and isolated
pathogen.
Compounds Spectrum Dose * Comment
Imipenem See cefepime, plus Gram-negative bacteria, 0.5 g every 6 hr Treatment of possible or proven presence of
Meropenem including Enterobacter species, and nonfermenters, 1 to 2 g every 8 hr multidrug-resistant Gram-negative bacteria
eg, P aeruginosa
Ertapenem See imipenem and meropenem, but no activity 1 g every 24 hr See imipenem or meropenem but often
against P aeruginosa applied for outpatient IVtreatment
Class: Glycopeptides Inhibition of the cell wall formation by blocking peptidoglycan synthesis. They bind to the amino acids within the cell wall, thereby interfering
with new units of the peptidoglycan chain.
Compounds Spectrum Dose* Comment
Vancomycin Gram-positive bacteria, staphylococci, streptococci, 15 mg / kg every 12 hr Treatment of possible or proven
Teicoplanin (Europe) Propionibacterium species, Enterococcus species 0.8 g loading dose on day 1, followed staphylococci (oxacillin-resistant),
by 0.4 g every 24 hr Enterococcus species (amoxicillin-resistant)

Class: Lipopeptide Inserts into to the cell membrane, alters the curvature, and thereby, creates holes in the membrane. Ions leak and cause a rapid
depolarization, leading to inhibition of essential bacterial products, and eventually to cell death.
Compounds Spectrum Dose* Comment
Daptomycin Gram-positive bacteria, staphylococci, streptococci, 610 mg / kg every 24 hr MIC of Enterococcus species must be tested
Enterococcus species prior to treatment.

Ta b le 5 -3 Most im portant antibiotics for intrave nous use in bone and joint infe ction [41, 6 8 ].
Abbre viations: MIC, m inimal inhibition conce ntration; OAI, oste oarticular infe ction; MRSA, m e thicillin-re sistant S aureus; ESBL, e xte nde d-
spe ctrum -lactam ase; IV, intrave nous.
*
Antim icrobial dosage re com m e ndations are base d on normal re nal and he patic function. Adaptations are re quire d in case of re nal or
he patic dysfunction.

In coagulase -ne gative staphylococci oxacillin-susce ptibility must be re liably te ste d.

Whe n using it for Pse udom ona s spe cie s, consult a m icrobiologist be cause of Am pC induction and re sistance de ve lopm e nt.

70 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

We rner Zimme rli, Parham Se ndi

4 Wh ich d ru gs a re im p o r t a n t in s ys t e m ic Neverth eless, or IV -lactam s, it is m ean in g u l to adm in ister

a n t ib io t ics? th e sam e dose or all th ree en tities.

an d Ta b le 5 -4 presen t a list o th e m ost com m on

Ta b le 5 -3
dru gs th at orth opedic su rgeon s sh ou ld be aw are o . Th e list
is n ot exh au stive, sin ce n ot every an tibiotic is available in
every region o th e w orld. Th e doses are recom m en ded or
patien ts w ith n orm al ren al an d liver u n ction . I th ese organ s
are im paired, doses m u st be adapted accordin gly. Wh eth er
th e dose or septic arth ritis, osteom yelitis, an d im plan t-as-
sociated in ection s sh ou ld di er rom on e an oth er h as n ot
been su cien tly in vestigated. Most an tibiotics h ave a good
seru m / syn ovial f u id con cen tration ratio [33 ]. Th ere ore,
recom m en dation s w ith low er doses an d/ or lon ger in tervals
o an tim icrobial adm in istration exist or septic arth ritis.
4 .1 Dru gs fo r e m p iric t h e ra p y
Orth opedic su rgeon s sh ou ld kn ow w h ich em piric th erapy
is th e m ost appropriate or a given patien t. Em piric sh ou ld
cover th e m ost com m on path ogen s cau sin g osteoarticu lar
in ection s, in clu din g staph ylococci, streptococci, an d en -
terobacteriaceae (see ch apter 3 Microbiology). Secon d, th e
con cept or em piric th erapy sh ou ld be establish ed rom local
resistan ce pattern s. Th u s, con stan t epidem iological su rveil-
lan ce o bacterial resistan ce pattern s, an d close collaboration
w ith m icrobiologists an d h ospital epidem iologists are n eces-
sary. In addition , adaptation s m u st be evalu ated i a tren d
or ch an ge occu rs in resistan ce pattern s. In areas w ith a low

Compound Spectrum* Bioavailability (%) Dose Comments

Amoxicillin P acnes, -hemolytic streptococci 7080 1 g every 8 hr Bone penetration after a single dose 1020%.
Amoxicillin/clavulanate P acnes, -hemolytic streptococci, anaerobes 7080 1 g every 8 hr Therefore, restricted to pathogens with low
MIC||
Clindamycin Staphylococci, streptococci, P acnes, anaerobes 90 0.30.45 g every 68 hr Determination of MIC and inducible
clindamycin resistance recommended
Ciprofloxacin Gram-negative bacteria, staphylococci when treated in 80 0.75 g every 12 hr Monitor side effects (Ta b le 5 -2 ), in
combination with rifampin particular in elderly patients
Levofloxacin Gram-negative bacteria, staphylococci when treated in > 90 0.5 g every 12 hr or Staphylococci have discreet lower MICs for
combination with rifampin 0.75 g every 24 hr levofloxacin than for ciprofloxacin
Moxifloxacin Gram-negative bacteria, staphylococci when treated in 90 0.4 g every 24 hr According to manufacture activity also against
combination with rifampin anaerobes
Minocycline Staphylococci, P acnes > 90 0.1 g every 12 hr For staphylococcal infection as suppressive
Doxycycline Staphylococci, P acnes > 90 0.1 g every 12 hr therapy or curative in combination with
rifampin
Cotrimoxazole Gram-negative bacteria , staphylococci when treated in > 90 1 double dose table every Monitor side effects (Ta b le 5 -2 ), in
combination with rifampin 8 hr particular in elderly patients
Fusidic acid Staphylococci 90 0.5 g every 8 hr Monitor compliance because high number of
tablets required
Rifampin Staphylococci when treated in combination with other > 90 0.3 to 0.45 g every 12 hr Never use rifampin as monotherapy
active antistaphylococcal antibiotic
Linezolid Gram-positive bacteria, staphylococci, enterococci > 90 0.6 g every 12 hr Monitor side effects (Ta b le 5 -2 ), in
particular in elderly patients
Metronidazole Anaerobes, Clostridium species >80 0.5 g every 8 hr Monitor neurotoxic side effects in case of
long-term treatment

Ta b le 5 -4 Most im portant antibiotics for oral use in bone and joint infe ction [41, 6 8 ].
Abbre viations: MIC, m inim al inhibition conce ntration.
*
Antim icrobials m ust be chose n on in vitro susce ptibility and afte r consultation of a m icrobiologists or infe ctious dise ase s spe cialist.

The bioavailability data are pre se nte d in rounde d pe rce ntage s.

Antim icrobial dosage re com m e ndations are base d on normal re nal and he patic function. Adaptations are re quire d in case of re nal or
he patic dysfunction.

The dosage s of IV ( Ta b le 5 -3 ) and oral formulation vary signi cantly. Howe ve r, highe r dosage s of the oral form ulation cannot be
adm iniste re d.
||
The authors only re com m e nd the se against oste oarticular infe ctions due to bacte ria with low m inim al-inhibition conce ntration (e g, P a cne s,
-he m olytic stre ptococci), and if the patie nt has no e vide nce of im paire d e nte ral absorption. The bioavailability of am oxicillin and am picillin
are highe r and m ore pre dictable than the one for pe nicillin V.

In gram -ne gative infe ctions, the curative e ffe ct in the pre se nce of a fore ign body m ate rial is unprove n.

71
 Se ct io n 1Principle s
5
Systemic
antibiotics
prevalen ce o oxacillin -resistan t staph ylococci an d exten ded
spectru m -lactam ase (ESBL)-produ cin g en terobacteria-
ceae, am oxicillin / clavu lan ate or ce u roxim e are com m on ly
u sed dru gs or em piric IV treatm en t. In con trast, in areas
w ith a h igh prevalen ce o oxacillin -resistan t staph ylococci
an d ESBL-produ cin g en terobacteriaceae, a glycopeptide (eg,
van com ycin ) an d a carbapen em (eg, m eropen em ) are o ten
u sed.
4 .2 Ris k fa ct o rs in flu e n cin g e m p iric t h e ra p y
Risk actors or th e presen ce o m u ltidru g-resistan t bacteria
in lu en ce th e ch oice o em piric th erapy. Th ere ore, it is
im portan t to screen th e patien ts h istory or previou s m i-
crobiological resu lts, in dicatin g th e resistan ce pattern o th e
patien ts m icrobiom e. In IV dru g u sers, th e in volvem en t o
P aeruginosa species or m eth icillin -resistan t S aureus (MRSA)
sh ou ld be con sidered [58]. Hospital tou rism sh ou ld also be
con sidered. I patien ts rom cou n tries w ith en dem ic m u lti-
dru g-resistan t bacteria (eg, th e Middle East) are tran s erred
to cou n tries w ith a low prevalen ce o ESBL-produ cin g
en terobacteriaceae an d MRSA, em piric treatm en t sh ou ld
be adapted accordin gly.
4 .3 Dru gs n o t t o u s e fo r o ra l t re a t m e n t
Oral orm u lation s o a ri am ycin (ri am pin , ri abu tin ), f u o-
roqu in olon es, clin dam ycin , cotrim oxazole, an d tetracyclin es
h ave excellen t bioavailability ( Ta b le 5 -4 ). Ceph alosporin s,
in con trast, do n ot. Th ere ore, alth ou gh u sed in IV orm u la-
tion s, th ese com pou n ds sh ou ld n ot be u sed in oral application s
in bon e an d join t in ection s. Oral orm u lation s o pen icillin
derivates gen erally h ave a low bioavailability an d sh ou ld
on ly be adm in istered in selected cases (eg, Propipionibacte-
rium acnes, -h em olytic streptococci) a ter previou sly h avin g
been treated su cien tly lon g w ith IV orm u lation , an d a ter
con su ltation w ith a m icrobiologist or in ectiou s diseases
specialist.
4 .4 Dru gs fo r m u lt id ru g-re s is t a n t gra m -n e ga t ive
b a ct e ria
Worrisom e epidem iological observation s are sh ow in g an
in crease in carbapen em ase-produ cin g bacteria: im plan t-
associated osteoarticu lar in ection s w ith th ese bacteria h ave
been reported [5 9]. In th ese cases, th e ch oice o possible
an tim icrobial agen ts is lim ited. Fos om ycin , n itro u ran toin ,
an d colistin are cu rren tly u sed in th ese cases. Oth er com pou n ds
are cu rren tly in trial evalu ation s (ce tazidim e/ avibactam )
[60, 61]. Experien ce rom oth er types o in ection s (eg, u rin ary
tract in ection ) sh ou ld n ot be in discrim in ately extrapolated
to osteoarticu lar in ection s. Given th e com plexity o th ese
in ection s an d th e lim ited active an tim icrobial agen ts avail-
able, in ectiou s diseases specialists, m icrobiologists, an d
72
ph arm acologists sh ou ld be in volved in th e treatm en t plan n in g
as soon as possible.
4 .5 Wh e n t o u s e rifa m p in
Ri am pin is an establish ed com pou n d in th e treatm en t o
staph ylococcal bon e an d join t treatm en t [6 2 ]. It m u st be
adm in istered on ly in com bin ation w ith an oth er com pou n d,
an d cu rren t data su pport its role on ly in in ection s du e to
ri am pin -su sceptible staph ylococci. Be ore evalu atin g w h en
to u se ri am pin , it is im portan t to determ in e th e in dication s
o th e com pou n d. An algorith m is proposed in Fig 5-1 .
4 .5 .1 Oste o a rticu la r in fe ctio n s w ith o u t fo re ign b o d y
m a te ria l
Th e ration ale or u sin g ri am pin in patien ts w ith ou t bio lm
in ection is its excellen t bioavailability. In th is con cept, on ly
th e com bin ation w ith a f u orqu in olon e h as been an alysed
in clin ical stu dies [6 3 ]. Becau se -lactam s m u st be given
in traven ou sly, th e u se o th e ri am pin / f u orqu in olon e com -
bin ation allow s an early tran sition rom paren teral to oral
th erapy. How ever, to avoid su perin ection w ith ri am pin -
resistan t bacteria, ri am pin com bin ation th erapy sh ou ld on ly
be started w h en w ou n ds are dry an d en teral absorption is
reliable.
4 .5 .2 Oste o a rticu la r in fe ctio n s a sso cia te d w ith im p la n ts
Th e ration ale or th e u se o ri am pin in th ese cases is its
activity again st bacteria adh erin g to an im plan t. Su ch in ec-
tion s are called bio lm in ection s. Th u s, ri am pin sh ou ld be
adm in istered as soon as possible w h en th e im plan t is retain ed.
Th ere are, h ow ever, im portan t issu es to con sider prior to
adm in isterin g th e com pou n d. It is pru den t n ot to u se ri am pin
too early in th e cou rse o in ection or tw o reason s. Firstly,
perioperative ri am pin th erapy in creases th e risk o su per-
in ection w ith ri am pin -resistan t staph ylococci by selection
pressu re on th e local lora [5 2 ]. Secon dly, em ergen ce o
resistan ce is h igh est w h en th e bacterial load is h igh [44, 64].
Th e au th ors recom m en d n ot startin g ri am pin com bin ation
th erapy u n til a ter all drain s are rem oved, th e w ou n d is dry,
an d th e bacterial load is low ered by su rgical treatm en t an d
in itial IV an tim icrobial th erapy. Wh en th is situ ation h as
been ach ieved, ri am pin can be added to th e establish ed
an tistaph ylococcal IV treatm en t (eg, IV f u cloxacillin plu s
oral ri am pin ). Th e tolerability o ri am pin can th ereby be
observed du rin g h ospitalization . On disch arge, th e IV com -
pon en t can be replaced by an an tistaph ylococcal com pou n d
w ith good bioavailability. As a irst option , th e au th ors
recom m en d a f u oroqu in olon e i bacteria are su sceptible to
it. Altern atives in th e case o lu oroqu in olon e-resistan t
bacteria are cotrim oxazole, tetracyclin e (eg, m in ocyclin e),
or clin dam ycin [39].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
We rner Zimme rli, Parham Se ndi

Staphylococcal osteoarticular
in ection

Rifampin susceptible
Yes No

Without implant material With implant material

Implant-adhering biofilm formation

No implant-adhering biofilm expected
expected

Fluoroquinolone susceptible Dry wounds

No Yes

No rifampin-combination therapy. Rationale for rifampin-combination Rationale for rifampin:

Continue IVtherapy or look for alternative therapy: oral compound with excellent compound with activity against adhering
oral drug with excellent bioavailability bioavailibility and antistaphylococcal staphylococci
activity

Switch from IVto orally as soon as Add rifampin to ongoing

wounds are dry and enteral absorption IVtreatment
is possible

Combine rifampin with

Fluoroquinolone susceptible
a fluoroquinolone No Yes

Replace IVtreatment and combine Replace IVtreatment and combine

rifampin with another active rifampin with a fluoroquinolone
antistaphylococcal agent

Fig 5-1 Propose d algorithm for the use of rifam pin in oste oarticular infe ctions.
Abbre viation: IV, intrave nous.

73
 Se ct io n 1Principle s
5
Systemic
antibiotics
5 Te a m w o rk
Th e treatm en t o osteoarticu lar in ection s requ ires in tegrated
an d coordin ated team w ork betw een orth opedic su rgeon s
an d in ectiou s diseases specialists. O ten oth er specialists
su ch as plastic su rgeon s, ph arm acologists, m icrobiologists,
path ologists, an d radiologists com plete th e team . Wh en a
patien t su ers rom a com plex bon e an d join t in ection ,
re erral to a specialized cen ter m u st be con sidered. Most
specialized cen ters h ave establish ed eith er an in terdisciplin ary
u n it or bon e an d join t in ection s, or clin ical rou n ds an d
regu lar case discu ssion s th at are per orm ed w ith an in ter-
disciplin ary team . Th ose w h o are n ot su rgeon s th ereby
im prove th eir kn ow ledge an d experien ce in th e ju dgem en t
an d m an agem en t o in traoperative n din gs an d pre- an d
postoperative w ou n ds, as w ell as th eir skills in in terpretin g
clin ical an d radiological im ages in th e eld o osteoarticu lar
in ection s. On th e oth er h an d, su rgeon s are able to associate
clin ical presen tation w ith a speci c m icroorgan ism (eg,
viru len t versu s low -grade) an d are in volved in th e m ost
im portan t issu es o h ygien e precau tion s, in im provin g
m icrobiological prean alysis to optim ize sam plin g resu lts,
an d in correctin g an tim icrobial treatm en t an d poten tial side
e ects. Th e in terdisciplin ary treatm en t con cept con tribu tes
to th e collegial atm osph ere an d im proves u rth er in terdis-
ciplin ary w ork. Th e au th ors are con vin ced th at th rou gh
su ch an in terdisciplin ary team e ort, patien ts w ill tru ly
ben e t rom treatm en t, an d m ore im portan tly, in adequ ate
treatm en t even ts w ill be avoided.
74
6 Co n clu s io n
In appropriate u se o an tim icrobial agen ts m ay dam age th e
patien ts h ealth . Th e m ost requ en t errors are prolon ged
an tibiotic proph ylaxis an d em piric th erapy w ith ou t con -
rm ed eviden ce o in ection . Un in ten ded im plication s o
an tim icrobial th erapy are ch an ge o th e patien ts m icrobiom e,
su perin ection w ith m ore di cu lt-to-treat m icroorgan ism s,
an d em ergen ce o resistan ce du rin g th erapy. Th ere ore, good
kn ow ledge abou t an tibiotics is n eeded or th e w h ole team
in volved in th e m an agem en t o patien ts w ith osteoarticu lar
in ection s. Th e kn ow ledge o bon e pen etration or m ost
an tibiotics is based on in vestigation s a ter a sin gle dose, an d
h en ce, lim ited a ter prolon ged treatm en t. Th ere ore, h igh
doses an d a prolon ged treatm en t are recom m en ded. How-
ever, or oral orm u lation s o an tibiotics, bon e pen etration
is better or f u oroqu in olon es, clin dam ycin , lin ezolid, an d
ri am pin , th an or pen icillin s an d ceph alosporin s. In addition ,
m ost bon e an d join t in ection s requ ire an tibiotics com bin ed
w ith su rgical treatm en t. Th ere ore, a team o specialized
ph ysician s, n am ely orth opedic su rgeon s an d in ectiou s dis-
eases specialists, is n eeded. Oth er specialists, su ch as plastic
su rgeon s, ph arm acologists, m icrobiologists, path ologists,
an d radiologists can be in volved i n eeded. Failu re o th erapy
m ay occu r or m an y di eren t reason s. Be ore ch an gin g
an tibiotic th erapy, th e reason or ailu re m u st be an alyzed.
Am on g oth er cau ses, it m ay be related to in adequ ate su rgery,
m issin g or in appropriate m icrobiological w ork-u p, dru g-dru g
in teraction , in adequ ate dose or du ration o an tim icrobial
th erapy, em ergen ce o resistan ce, or n on com plian ce o th e
patien t.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
We rner Zimme rli, Parham Se ndi
7 Re fe re n ce s
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5
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ce tolozan e/ tazobactam tested again st
Pseu dom on as aeru gin osa an d
En terobacteriaceae w ith variou s
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61. Fa rre ll DJ, Sa d e r HS, Fla m m RK, e t a l.
Ce tolozan e/ tazobactam activity tested
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Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Volke r Alt
6 Lo ca l d e live ry o f a n tib io tics a n d a n tis e p tics
Vo lke r Alt
1 Ba s ics
Th e treatm en t an d preven tion o bon e an d im plan t-associ-
ated in ection s is based on tw o prin ciples: th orou gh su rgical
debridem en t an d in telligen t u se o an tibiotics an d an tiseptics.
Th e goal o local u se o an tibiotics an d an tiseptics is to deliver
h igh local con cen tration s o th e an tim icrobial agen ts to
eradicate bacteria w ith low system ic levels o th e an tibiotic
to redu ce th e likelih ood o adverse system ic e ects. Local
adm in istration o an tibiotics ach ieve h igh con cen tration s
w h ere n eeded w ith redu ced risks or system ic adverse even ts.
Fu rth erm ore, local an tim icrobial th erapy en ables access o
th e agen ts to poorly vascu larized in ected bon e, wh ich can n ot
be ach ieved by in traven ou s th erapy alon e.
Th e su rgeon requ ires detailed kn ow ledge o th e di eren t
an tibiotic adm in istration m eth ods or th e su ccess u l m an -
agem en t o open ractu res, bon e- an d im plan t-associated
in ection cases. Th e u se o an tim icrobial agen ts does n ot
replace proper su rgical debridem en t an d sh ou ld be con sidered
an adju n ctive tool in th e arm am en tariu m o th e su rgeon .
Th e goal o th is ch apter is to give an overview o th e di eren t
an tiseptics, an tibiotics, an d delivery system s to provide a
practical gu idelin e or th eir su ccess u l in traoperative u se.
Fu rth erm ore, th e clin ical aspects o an tim icrobial-coated
im plan ts w ill be elu cidated.
2 An t is e p t ics
An tiseptics are an tim icrobial su bstan ces th at can be applied
to w ou n ds to eradicate bacteria. In con trast to an tibiotics,
an tiseptics can n ot be adm in istered system ically an d can on ly
be u sed locally to m an age in ected or con tam in ated tissu e.
Disin ectan ts also exh ibit an tim icrobial properties bu t can
on ly be u sed on in an im ate objects.
In orth opedic an d trau m a su rgery, polyh exan ide, octen idin e
dih ydroch loride, an d povidon e-iodin e are th e m ost re-
qu en tly u sed an tiseptics.
2 .1 Po lyh e xa n id e
Polyh exan ide is a com m on ly u sed an tiseptic agen t or in -
ected or critically colon ized wou n ds, in clu din g poorly h ealin g
an d ch ron ic w ou n ds. It is also u sed in an tiseptic w ou n d
dressin gs [1]. It is th e an tiseptic o ch oice or con tam in ated
acu te trau m atic w ou n ds. It is u n gicidal an d bactericidal
in clu din g activity again st m eth icillin -resistan t Staphylococcus
aureus (MRSA) an d van com ycin -in term ediate sen sitivity S
aureus (VISA). Gaps in e ectiven ess are n ot kn ow n an d
e ectiven ess again st bio lm -dw ellin g organ ism s h as been
reported [1]. Polyh exan ide h as a relatively slow on set o
an tibacterial activity o 520 m in u tes in qu an titative su spen -
sion test or a con cen tration o 0.04% . It h as selective activ-
ity again st acidic lipids o bacterial cell m em bran es w ith on ly
a m in or e ect on th e n eu tral lipids o h u m an cell m em bran es.
Th is is th e reason or its excellen t biocom patibility. It h as
been ou n d to prom ote w ou n d h ealin g. Th ese properties
distin gu ish polyh exan ide rom m ost oth er an tiseptics. Con -
train dication s in clu de:
Periton eal lavage
In traven ou s application
Join t lavage on h yalin e cartilage (> 0.005% ) du e to
cartilage toxicity
Use in an y part o th e cen tral n ervou s system , m iddle
or in n er ear
In traocu lar application s [1]
77
 Se ct io n 1Principle s
6Local
de livery
of
antibiotics
and
antise ptics
2 .2 Oct e n id in e d ih yd ro ch lo rid e
Octen idin e dih ydroch loride (OCT) can be con sidered as an
excellen t an tiseptic or acu te con tam in ated trau m atic
w ou n ds an d as an an tiseptic o ch oice or ch ron ic w ou n ds.
It h as a broad an tibacterial spectru m on gram -positive an d
gram -n egative bacteria. It also exh ibits an ti u n gal activity
an d an tiviral activity again st en veloped viru ses su ch as h erpes
sim plex an d h epatitis B [1]. Du rin g su rgery, n o pressu rized
irrigation o cavities w ith ou t adequ ate ou tf ow sh ou ld be
per orm ed. Octen idin e dih ydroch loride exh ibits toxicity to
h yalin e cartilage an d is con train dicated or u se in perito-
n eal lavage.
2 .3 Po vid o n e -io d in e
In dication s or povidon e-iodin e are lim ited to stab, cu t, an d
bite w ou n ds [1]. Th is is m ain ly related to th e system ic toxic-
ity w ith n egative e ects on th yroid u n ction an d deleteriou s
e ects on w ou n d h ealin g com pared to polyh exan ide. In
vivo resu lts h ave sh ow n in h ibition o w ou n d h ealin g by
povidon e-iodin e even at low con cen tration s o 0.75% . It
h as m icrobicidal properties again st gram -positive an d gram -
n egative bacteria, u n gi, an d protozoa. It is e ective again st
h epatitis B viru s, h epatitis C viru s, an d h u m an im m u n ode-
cien cy viru s. It exh ibits a rapid on set o activity.
2 .4 Ch lo rh e xid in e (glu co n a t e / d iglu co n a t e )
Ch lorh exidin e sh ou ld n ot be u sed as a w ou n d an tiseptic. It
possesses low e ectiven ess again st gram -n egative clin ical
isolates com bin ed w ith a decrease o activity in th e presen ce
o protein s an d blood. Ch lorh exidin e is cytotoxic, w h ich
resu lts in w ou n d h ealin g problem s; possible allergic reac-
tion s an d poten tially a m u tagen ic poten tial h ave also been
described [1].
2 .5 An t is e p t ic u s e in o p e n fra ct u re s
Th e prin ciples o in itial m an agem en t o open ractu res in clu de
in traven ou s an tibiotics, m eticu lou s w ou n d debridem en t,
an d irrigation ollow ed by stabilization o th e ractu re. A
variety o di eren t additives, su ch as povidon e-iodon e,
ch lorh exidin e, or castile soap solu tion , an d di eren t pres-
su res at w h ich f u id is delivered to th e w ou n d h ave been
described in th e literatu re [2 4 ].
78
In a recen t ran dom ized con trol trial o f u id lavage o open
w ou n ds (FLOW) on 111 patien ts, th e poten tial di eren ces
in ou tcom e between irrigation with castile soap versu s irriga-
tion w ith n orm al salin e w as per orm ed. An irrigation volu m e
o at least 3 L an d 6 L w as u sed or Gu stilo-An derson type
I an d type II/ III open ractu res, respectively. In th e castile
soap grou p, 80 m L o castile soap solu tion w as added to each
3 L o n orm al salin e. Fu rth erm ore, low (610 psi) versu s
h igh pressu re (2530 psi) or th e delivery o th e irrigation
lu id w as assessed. Th ere w as n o statistically sign i ican t
di eren ce n oted betw een th e u se o castile soap u n d n orm al
salin e or irrigation in open ractu res w ith th e prim ary com -
posite ou tcom e o reoperation procedu res or in ection ,
w ou n d h ealin g problem s, an d n on u n ion , m easu red at 12
m on th s a ter in itial operative procedu re [2]. Th ere w as an
apparen t in crease in th e in ection rate in th e castile soap
grou p com pared to n orm al salin e. Th e au th ors discu ssed a
poten tial rebou n d e ect in bacterial grow th a ter in itial
irrigation o an open w ou n d in th e castile soap grou p w h ich
w as previou sly ou n d to be w orse w ith castile soap com pared
to salin e alon e or to salin e w ith oth er additives [3 ]. An
altern ative explan ation is th at th e soap acts as local irritan t
or th e skin leadin g to local eryth em a an d su bsequ en t in ec-
tion . An oth er previou s ran dom ized con trolled stu dy w ith
400 patien ts w ith 458 open ractu res also sh ow ed n o ad-
van tages o th e irrigation o open ractu re w ou n ds w ith
an tibiotic solu tion over th e u se o a n on sterile soap solu tion
[5]. In an open ractu re experim en t u sin g an an im al, th ere
w as n o statistically sign i can t di eren ce n oted betw een
salin e an d ch lorh exidin e glu con ate regardin g th e su bsequ en t
presen ce or qu an tity o bacteria a ter irrigation [4]. Th is stu dy
also discou raged th e u se o ch lorh exidin e glu con ate in open
ractu res. Regardin g irrigation pressu re, th e f u id lavage o
open w ou n ds in vestigators ou n d n o statistically sign i can t
di eren ce betw een low an d h igh pressu re, bu t th e resu lts
revealed a stron g tren d in avor o low -pressu re pu lsatile
lavage [2].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Volke r Alt
3 An t ib io t ics a n d ca rrie rs
In gen eral, m an y di eren t an tibiotics can be u sed w ith di -
eren t carriers or local adm in istration . Th e m ost requ en tly
u sed local an tibiotics are gen tam icin , tobram ycin , an d van -
com ycin . Carriers can be distin gu ish ed in to n on degradable
versu s biodegradable m aterials. Th e m ost requ en tly u sed
n on degradable carrier is polym eth ylm eth acrylate (PMMA).
Calciu m su l ate or collagen -based carriers are also u sed as
biodegradable m aterials. Ri am pin can n ot be u sed w ith
PMMA bu t can be u sed w ith resorbable carriers. Recen tly,
bioactive glass w ith its com bin ation o an tim icrobial an d
osteocon du ctive properties h as becom e an addition al option .
3 .1 Lo ca l a n t ib io t ics
An tibiotics th at can be u sed or local adm in istration in
orth opedic an d orth opedic trau m a su rgery m u st u l ill
several precon dition s. Th ey h ave to be e ective again st th e
in ection -cau sin g m icroorgan ism . Bactericidal an tibiotics
are pre erred over bacteriostatic an tibiotics. Bioavailability
rom th e carrier o th e an tibiotic m u st be en su red. An tibiotic
h eat stability is o h igh im portan ce w h en PMMA is u sed as
carrier, as th e exoth erm ic polym erization procedu re can
lead to tem peratu res o 80 C [6]. For PMMA loadin g, th e
an tibiotic m u st be u sed in pow der orm becau se liqu id an -
tibiotics dram atically w eaken th e stren gth o PMMA [7 ].
Liqu id an tibiotics are m ore avorable or th e loadin g o
degradable carriers. For acilitation o an tibiotic release,
w ater solu bility an d h ydroph ilic properties are im portan t.
Fu rth erm ore, th e an tibiotic sh ou ld n ot be cytotoxic to eu -
karyotic cells an d sh ou ld n ot in ter ere w ith ractu re h ealin g.
Gen eral system ic side e ects an d allergic pro le m u st also
be con sidered.
Th e m ost requ en tly u sed local an tibiotics are: gen tam icin ,
tobram ycin , an d van com ycin . Ri am pin can n ot be u sed in
com bin ation w ith PMMA as it in ter eres w ith its polym er-
ization [8 ]. Ri am pin can be u sed w ith a calciu m su l ate-
h ydroxyapatite carrier [9].
Despite gen erally accepted excellen t biocom patibility [10],
case reports h ave been pu blish ed docu m en tin g acu te ren al
ailu re as system ic com plication in patien ts cau sed by gen -
tam icin -, tobram ycin -, or van com ycin -loaded spacers [1113].
Th is em ph asizes th e n eed or care u lly con sidered dosage,
in creased vigilan ce, an d pru den t m on itorin g in patien ts at
in creased risk or n eph rotoxicity .
3 .1.1 Ge n ta m icin a n d to b ra m ycin
Gen tam icin an d tobram ycin are bactericidal am in oglycoside
an tibiotics th at bin d to th e 30S su bu n it o th e bacterial
ribosom e w ith su bsequ en t in terru ption o protein syn th esis.
In ection s w ith S aureus or gram -n egative bacteria su ch as
Pseudomonas, Proteus, or Serratia can be treated w ith gen ta-
m icin or tobram ycin . Th e h igh h eat resistan ce an d avorable
release kin etics m ake gen tam icin an d tobram ycin su itable
or loadin g w ith PMMA an d th eir u se w ith PMMA h as been
w ell establish ed an d proven clin ically e ective [10 ]. Gen ta-
m icin an d tobram ycin at con cen tration s u p to 400 g/ m L
did n ot dem on strate n egative e ects on th e m etabolic activ-
ity on h u m an osteoblasts [14].
3 .1.2 Va n co m ycin
Van com ycin is an an tibiotic o th e glycopeptide class. It sh ow s
h igh an tim icrobial activity again st m ost gram -positive
bacteria, eg, S aureus, in clu din g MRSA, w h ich is th e ration ale
or its u se in m an y cases w ith docu m en ted or su spected
in ection s w ith MRSA. Van com ycin is th e secon d m ost
requ en tly u sed an tibiotic in PMMA a ter am in oglycosides
alth ou gh its h igh m olecu lar w eigh t o > 600 Dalton s resu lts
in less avorable bu t acceptable release kin etics [15]. Van co-
m ycin w as sh ow n at con cen tration s o < 1,000 g/ m L to
h ave n o or on ly m in im al e ects on th e replication o osteo-
blasts. In very h igh con cen tration s > 10,000 g/ m L van co-
m ycin can lead to eu karyotic cell death [16].
3 .1.3 Rifa m p in
Ri am pin belon gs to th e ri am ycin grou p an d exh ibits bac-
tericidal activity by in h ibitin g bacterial deoxyribon u cleic
acid-depen den t ribon u cleic acid syn th esis. In bon e an d
im plan t-associated in ection s, ri am pin is a corn erston e o
th e an tibiotic treatm en t du e to its excellen t activity again st
S aureus in clu din g MRSA bu t also again st en terococci [17,
18]. An oth er m ajor advan tage is its alm ost u n iqu e ability to
eradicate bacteria in bio lm s th at h as been dem on strated
in several experim en tal an d clin ical stu dies [19, 20]. Ri am pin
sh ow s good biocom patibility w ith bon e cells w ith in tracel-
lu lar an tibiotic activity in osteoblasts gh tin g in tracellu lar
bacteria su ch as S aureus [21]. Mon oth erapy w ith ri am pin
sh ou ld be avoided du e to rapid developm en t o resistan ce.
Major adverse even ts are h epatotoxicity, allergic reaction s,
reversible n eu tropen ia, an d th rom bocytopen ia. Ri am pin
can cau se an oran ge colorin g o body f u ids su ch as u rin e,
tears, sw eat, an d stools w ith ou t an y n egative clin ical im pact.
As m en tion ed above, th e in ter eren ce w ith th e polym eriza-
tion o PMMA preven ts its u se in bon e cem en t [8] bu t it is
su itable or th e loadin g o a degradable carrier [9].
79
 Se ct io n 1Principle s
6Local
de livery
of
antibiotics
and
antise ptics

3 .1.4 Da p to m ycin Co m m e rcia lly a va ila b le ge n ta m icin -lo a d e d PMMA b e a d s

Daptom ycin h as recen tly been sh ow n to be u sable in PMMA
cem en t. It is less e ective th an van com ycin w h en u sed as
m on oth erapy bu t is m ore e ective i u sed in com bin ation
w ith an am in oglycoside in th e PMMA cem en t [22, 23].
3 .2 Ca rrie rs
Th e m ost com m on ly u sed n on resorbable an tibiotic carrier
is PMMA. Di eren t com m ercially available an tibiotic-loaded
PMMA bon e cem en ts an d an tibiotic-loaded PMMA bead
ch ain s are available. Th ere are on ly a ew biodegradable
delivery biom aterials based on collagen , calciu m su l ate,
calciu m ph osph ate, or an tibiotic-loaded can cellou s bon e
allogra ts.
3 .2 .1 Po lym e th ylm e th a cryla te
Th e idea o local delivery o an tibiotics via PMMA as a
carrier an d dru g delivery system w as in trodu ced in th e 1970s
by Bu ch h olz an d En gelbrech t in th e treatm en t o in ected
total join t replacem en ts [24]. Klem m [25] adapted th is prin -
ciple to th e treatm en t o ch ron ic osteom yelitis to ach ieve
h igh local an tibiotic con cen tration w ith th e u se o an tibiot-
ic-loaded PMMA beads th at cou ld be directly applied in to
th e in ected bon e tissu e.
Com m ercially available gen tam icin -loaded PMMA beads
m u st be distin gu ish ed rom h an dm ade PMMA beads. On e
com m on ly u sed produ ct is a gen tam icin -loaded PMMA bead
ch ain w h ich is available w ith di eren t len gth s ( Fig 6 -1 ). Th e
beads h ave a diam eter o 7 m m , a w eigh t o 200 m g an d
con sist o PMMA w ith 7.5 m g gen tam icin su l ate correspon d-
in g to 4.5 m g gen tam icin , a sm all am ou n t o glycin e or
im provem en t o release kin etics an d 20 m g o th e radio-
opaqu e zircon iu m . Also, th ere are so-called m in ich ain s
w ith 10 or 20 beads w ith a size o 3 x 5 m m w ith 2.8 m g o
gen tam icin su l ate correspon din g to 1.7 m g o gen tam icin ,
available or sm aller bon e de ects. Th e beads are stru n g on
a th in ch rom iu m -n ickel w ire. O cial in dication s o th ese
beads are th eir tem porary u se in su rgically treated bon e an d
so t-tissu e in ection s w ith gen tam icin -su sceptible strain s.
Con train dication s are allergies to gen tam icin an d th e carrier
m aterial. In case o n ickel or oth er m etal allergies, tissu e
reaction s cou ld occu r to th e ch rom iu m an d n ickel con ten t
in th e m etal w ire.

Th ere are di eren t orm s an d in dication s or an tibiotic-

loaded PMMA carriers. First, th e proph ylactic u se o low -dose
PMMA bon e cem en t or in ection proph ylaxis in prim ary
total join t arth roplasty. Secon d, th ere is a th erapeu tic u se
o an tibiotic PMMA devices as an tibiotic-loaded PMMA beads
in osteom yelitis an d in ected n on u n ion cases, or spacers
a ter rem oval o a join t prosth esis in th e tw o-stage revision
con cept or periprosth etic join t in ection s. Th e last is ex-
plain ed u rth er in ch apter 10 In ection a ter join t arth ro-
plasty. A n ew con cept w as in trodu ced by Masqu elet an d
colleagu es [26 ] u sin g solid an tibiotic-loaded PMMA spacers
a ter resection o in ected bon e tissu e or both local delivery
o an tibiotics an d in du ction o an osteogen ic m em bran e th at
Fig 6-1 Com m e rcially available polym e thylm e thacrylate (PMMA)
stim u lates n ew bon e orm ation in th e cou rse o bon e be ads. Chain with 30 PMMA be ads with a be ad diam e te r of 7 m m
recon stru ction o th e de ect in th is tw o-stage treatm en t consisting of 7.5 m g ge ntam icin sulfate and m inichain with 10
con cept. be ads of 3 x 5 m m with 2.8 mg of ge ntamicin sulfate .

80 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Volke r Alt

Elu tio n kin e tics o f co m m e rcia lly a va ila b le ge n ta m icin - Seru m con cen tration s o 0.030.4 g/ m L an d a ren al excre-
lo a d e d PMMA b e a d s tion rate o 340 g/ m in w ere m easu red in ive patien ts
Elu tion o an tibiotics rom PMMA gen erally depen ds on treated w ith 48360 beads [29]. No sign s o n eph rotoxicity
th e su r ace an d porosity o PMMA w h ich can be in creased or oth er system ic adverse e ects w ere detected. To th e au -
by th e in corporation o glycin e or ce azolin as porogen s. th ors best kn ow ledge, on ly on e clin ical case report on a
Th is is on e o th e prin ciples in gen tam icin -loaded PMMA patien t exists th at developed en d-stage ren al dys u n ction
beads. Both th e total qu an tity o an tibiotics an d th e com - a ter bein g treated w ith a com bin ation o 210 beads an d
position o th e bon e cem en t com pon en ts a ect th e elu tion cem en t con tain in g 2 g gen tam icin in 240 g cem en t pow der.
kin etics [27]. A ter rem oval o th e m aterials con tain in g gen tam icin , ren al
u n ction n orm alized. In su m m ary, th e u se o com m ercially
Th e release process o gen tam icin rom PMMA is a di u sion available gen tam icin beads is typically sa e. How ever, th e
process as in all an tibiotic-loaded PMMA devices [28] th rou gh above-m en tion ed con train dication s sh ou ld be con sidered.
w h ich gen tam icin is exch an ged w ith th e su rrou n din g body
lu id. Th e an tibiotic is th en tran sported to th e adjacen t Com m ercially available PMMA beads o er th e advan tage
tissu e ollow in g a con cen tration gradien t. Clin ical data sh ow o reliable release beh avior o gen tam icin , w h ereas h an d-
h igh local con cen tration s o gen tam icin in th e rst days in m ade beads carry th e risk o an u n even distribu tion o th e
th e w ou n d f u id u p to 200300 g/ m L a ter application o an tibiotic in th e PMMA w ith su bsequ en t u n predictable
360 gen tam icin beads in a tw o-stage h ip in ection treatm en t release beh avior [34].
[29]. Th is is m u ch h igh er th an th e m in im al in h ibitory con -
cen tration th at kills 90% o th e strain s (MIC9 0 ) o 1 g/ m L
o S aureus [3 0 ]. In con trast, gen tam icin con cen tration s
reach ed on ly 0.4 g/ m L in seru m an d on ly 1030 g/ m L in
u rin e. Th e total released am ou n t o gen tam icin a ter a treat-
m en t o 914 days w as 2070% o th e in corporated gen ta-
m icin . Jen n y et al [31] pu blish ed clin ical data on gen tam icin
con cen tration s in th e drain age f u id on postoperative day
on e in 188 patien ts treated w ith 3390 gen tam icin -loaded
PMMA beads. Mean con cen tration s o 16 g/ m L or a treat-
m en t w ith 17 beads an d o 420 g/ m L or a treatm en t w ith
156 beads w as ou n d con irm in g h igh local gen tam icin
con cen tration s th at is above th e MIC90 o 1 g/ m L o S aureus.
How ever, n o correlation betw een th e n u m ber o im plan ted
beads an d m ean gen tam icin con cen tration s cou ld be dem -
on strated, w h ich m akes it im possible to reliably predict th e
actu al ach ievable local an tibiotic con cen tration or an in di-
vidu al patien t im possible. A ter an in itial relatively h igh -bu rst
release, a con sequ en tly su bth erapeu tic release is m ost likely
[32, 33].

81
 Se ct io n 1Principle s
6Local
de livery
of
antibiotics
and
antise ptics

Su rgica l h a n d lin g o f co m m e rcia lly a va ila b le ge n ta m icin -
lo a d e d PMMA b e a d s
Regardin g th e su rgical h an dlin g o gen tam icin -loaded PMMA
beads, th e ollow in g sh ou ld be con sidered. First, a th orou gh
su rgical debridem en t o th e in ected site m u st be per orm ed.
Th e local an tibiotics are n ot a su bstitu te or an appropriate
su rgical procedu re. On ly w h en all in ected an d com prom ised
tissu e h as been debrided an d th e w ou n d h as been su -
cien tly irrigated, th e application o th e an tibiotic beads in to
th e debrided bon e or so t-tissu e area is per orm ed ( Fig 6 -2 )
[3 5 ] at th e en d o th e procedu re. A drain w ith ou t su ction
m ay be placed as n egative-w ou n d pressu re cou ld lead to
w ash ou t o th e an tibiotics via th e drain . Th e drain can be
rem oved rou tin ely a ter 13 days depen din g on th e am ou n t
o drain age an d su rgeon s pre eren ce. Polym eth ylm eth ac-
rylate beads sh ou ld be rem oved a ter 24 w eeks du e to th e
decreased am ou n t o released an tibiotic w h ich carries th e
risk o th e presen ce o su bin h ibitory an tibiotic con cen tration s
w ith developm en t o resistan ce an d su bsequ en t colon ization
o th e beads w ith resistan t bacteria. Th is cou ld serve as a
reservoir o th e in ection [32, 33].
An tibiotic-loaded PMMA beads are com m ercially available
on ly in Eu rope, th ere ore in m ost parts o th e w orld PMMA
beads are h an dm ade or local an tibiotic th erapy.

a b c
Fig 6-2a c Application of antibiotic be ads.
a Intraope rative use of a comm e rcially available polym e thylm e thacrylate (PMMA) be ads.
b c Place m e nt of a chain with 3 0 PMMA be ads around an acute ly infe cte d locking plate at the distal fe m ur. X-ray controls afte r intram e dullary
place m e nt of 30 be ads into the tibia, 10 be ads into the infe cte d tibial nonunion site , and e xtram e dullary place m e nt of 10 be ads be side
the infe cte d proxim al bula ( b AP vie w; c late ral vie w).

82 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Volke r Alt
Ha n d m a d e a n tib io tic-lo a d e d PMMA b e a d s
Th e advan tage o h an dm ade an tibiotic-loaded PMMA beads
is th at n ot on ly gen tam icin bu t a variety o oth er an tibiotics
can be u sed depen din g on th e an tibiotic su sceptibility o th e
in ection -cau sin g m icroorgan ism , particu larly i th ere is
gen tam icin resistan ce. Han d-m ixed an tibiotic beads are
gen erally less expen sive th an com m ercially available beads.
Fu rth erm ore, th e syn ergistic e ect betw een am in oglycosides
an d van com ycin or elu tion kin etics rom PMMA an d an -
tim icrobial e ectivity can be leveraged wh en both an tibiotics
are in corporated in h an d-m ixed bon e cem en t ( Ta b le 6 -1 )
[36, 37].
Elu tio n kin e tics o f h a n d m a d e PMMA b e a d s
An agn ostakos et al [36] an alysed th e elu tion kin etics o 40
h an dm ade PMMA beads loaded w ith 0.5 g o gen tam icin
an d 2 g o van com ycin per 40 g o PMMA in th e w ou n d
drain age o 11 patien ts over 713 days. Peak m ean con cen -
tration s o 116 g/m L o gen tam icin w ith a ran ge o 12371
g/m L an d m ean con cen tration s o 80 g/m L o van com ycin
w ith a ran ge o 21198 g/m L w ere m easu red on day 1
( Fig 6 .3 ). Low est con cen tration s o 3.7 g/ m L an d 23 g/ m L
w ere ou n d on day 13 or gen tam icin an d van com ycin ,
respectively. Th e au th ors attribu ted th e h igh in tersu bject
variability o th e release o both an tibiotics to th e m an u al
in corporation o van com ycin in to th e cem en t pow der. How -
ever, in all cases th e con cen tration s on day 13 are still above
th e MIC9 0 o S aureus or gen tam icin an d van com ycin . No
h epatic or ren al dys u n ction w as observed an d, th ere ore,
th is dosage appeared sa e or h an dm ade PMMA beads.
Rasyid et al [3 8 ] presen ted a m eth od to im prove release
kin etics rom h an dm ade gen tam icin PMMA beads, ie, 1 g o
gen tam icin su l ate an d 40 g o PMMA pow der, w ith addition
o on ly 50% o m on om er to create a less den se polym er
m atrix. Th e addition o 15% by weigh t o polyvin ylpyrrolidon e
(PVP) 17 as gel- orm in g polym eric f ller w as ou n d to u rth er
Antibiotic Dosage Potential side effects
Gentamicin 1 g per 40 mg PMMApowder Allergic reactions
Nephrotoxicity
Tobramycin 1 g per 40 mg PMMApowder Allergic reactions
Nephrotoxicity
Gentamicin and vancomycin 0.5 g gentamicin and Allergic reactions
2 g vancomycin per 40 mg PMMA Nephrotoxicity
Ta b le 6 -1 Suitable antibiotics and dosage s for handm ade
polym e thylm e thacrylate (PMMA) be ads.
optim ize release kin etics w h ich w as even better th an th e
on e o com m ercially available beads or 14 days in vitro.
Th is is a ch eap an d e ective m eth od to im prove release
beh avior o gen tam icin in h an dm ade PMMA beads.
Besides th is stu dy, th ere is lim ited clin ical in orm ation on
th e elu tion kin etics o oth er h an dm ade an tibiotic-loaded
PMMA beads in patien ts an d, th ere ore, n o u rth er recom -
m en dation on specif c an tibiotic com bin ation s an d dosages
can be m ade. Citak et al [10] pu blish ed in th e Proceedin gs
o th e In tern ation al Con sen su s Meetin g on Periprosth etic
Join t In ection a table w ith all clin ically reported an tibiotic
loadin gs or spacers in patien ts or treatm en t o peripros-
th etic join t in ection s. How ever, it m u st be stated th at th is
in orm ation is on ly valid or PMMA block spacers an d n ot
or PMMA beads as th e latter h ave a h igh er su r ace w ith
th e th eoretical risk o u n desirable release kin etics i h igh
spacer dosage is u sed or beads.
400
Ge n ta m icin
Va n co m ycin
300
200
100
0
1 2 3 4 5 6 7 8 9 10 11 12 13
Da y
Fig 6-3 Re le ase kine tics of ge ntam icin and vancomycin of 4 0
handm ade polym e thylm e thacrylate (PMMA) be ads loade d with
0 .5 g of ge ntam icin and 2 g of vancomycin pe r 4 0 g of PMMA in the
wound drainage of 11 patie nts ove r the rst 13 days (with pe rmission
from Anagnostakos e t al [39 ], Taylor & Francis Ltd. www.tandfonline .
com).
83
 Se ct io n 1Principle s
6Local
de livery
of
antibiotics
and
antise ptics
Pra ctica l tip s fo r m a n u fa ctu re o f h a n d m a d e PMMA b e a d s
For practical aspects in h an d m ixin g, th e an tibiotic pow der
sh ou ld be placed in a m ixin g con tain er u n der sterile con di-
tion s an d th en th e sam e am ou n t o PMMA as th e an tibiotic
pow der sh ou ld be added correspon din g to m ixtu re prin ciples
in ph arm acy to ach ieve h om ogen ou s distribu tion o th e
an tibiotic in th e PMMA beads [4 0 ]. A ter m ixin g w ith a
spatu la, an oth er PMMA am ou n t equ al to th e an tibiotic
PMMA pow der m ixtu re in th e con tain er is added an d m ixed.
Th is is con tin u ed u n til th e PMMA polym er pow der is u sed
u p. A ter addition o th e m on om er th e h arden in g an tibiot-
ic-loaded cem en t is th en u sed to orm th e beads. For th e
m an u actu rin g o th e beads, m olds can be produ ced or
pu rch ased [41, 42] th at h elp to stan dardize th e size an d orm
o th e beads.
a b
Fig 6-4a d Masque le t te chnique .
a b X-ray se rie s of a Sta phylococcus a ure us-infe cte d distal ulnar shaft nonunion and two -stage Masque le t te chnique tre atm e nt. Re se ction of
the infe cte d nonunion and place m e nt of a ge ntamicin-loade d polym e thylm e thacrylate space r into the de fe ct (stage one).
cd Stage two proce dure with re m oval of the space r and corticocance llous autoge nous bone graft from the iliac cre st and locking plate
xation 6 we e ks afte r stage one .
84
Ha n d m a d e a n tib io tic-lo a d e d sp a ce rs fo r Ma sq u e le t
te ch n iq u e
Th e ph ilosoph y o th e Masqu elet tech n iqu e is based on a
tw o-stage su rgical procedu re w ith placem en t o an an tibi-
otic-loaded PMMA in a resected bon e de ect a ter debridem en t
in a rst stage [26] ( Fig 6 -4 a b ). Th is stage is in ten ded both
to eradicate rem ain in g bacteria by released an tibiotics an d
in du ction o a biological active m em bran e on th e su r ace o
th e PMMA spacer. A ter 68 w eeks, th e secon d step is
per orm ed w ith care u l rem oval o th e spacer in w h ich th e
PMMA-in du ced m em bran e is in cised care u lly an d le t in
place ollow ed by illin g o th e space th at w as in itially
occu pied by th e PMMA spacer w ith au togra t an d/ or bon e
su bstitu tes or bon y con solidation ( Fig 6 -4 cd ). Th e m em bran e
th at is in du ced by PMMA over 68 w eeks is vascu larized
an d con tain s a certain am ou n t o grow th actors su ch as
vascu lar en doth elial grow th actor (VEGF), tran s orm in g-
grow th actor -1 (TGF -1), an d bon e m orph ogen etic pro-
tein -2 (BMP-2) providin g a positive biological en viron m en t
or th e bon y con solidation o th e de ect [43].
c d
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Volke r Alt

Pra ctica l tip s fo r th e Ma sq u e le t te ch n iq u e
Han d m ixin g o th e an tibiotic-loaded PMMA is per orm ed
as described above an d th e spacer is th en in trodu ced in to
th e bon e de ect betw een th e bon e edges. It sh ou ld su rrou n d
th e proxim al an d distal tw o bon e en ds o th e de ect to
create a w rap or th e bon e gra t in th e secon d procedu re
[44]. For stage tw o, th e m em bran e su rrou n din g th e PMMA
spacer sh ou ld be in cised care u lly ollow ed by rem oval o
th e spacer. Th e m edu llary cavity sh ou ld be debrided an d
open ed an d th e cortical bon e sh ou ld also be decorticated.
Th e de ect is th en lled w ith can cellou s bon e gra t w ith
sm all pieces o 12 m m 3 an d/ or bon e su bstitu tes w ith in th e
m em bran e an d th e m em bran e sh ou ld th en be closed again .
For recon stru ction o th e tibia, th e PMMA spacer m ay be
placed in con tact w ith th e bu la i a con stru ct or th e gra t-
tibia- bu la is desired.
In a series o 84 patien ts w ith large diaph yseal lon g bon e
de ects, con solidation w as ach ieved in 90% , an d bon e de ects
o u p to 230 m m in th e tibial diaph ysis w ere su ccess u lly
treated w ith th is tech n iqu e [44].
3 .2 .2 Co lla ge n
Collagen h as been stu died exten sively as a degradable carrier
du e to its biocom patibility, low cost, an d availability [4 5 ].
An tibiotic-loaded collagen f eeces are based on collagen rom
bovin e or equ in e skin or so t ten don an d can also act as
h em ostatic agen ts [6]. Th ere are several produ cts com m er-
cially available. Both produ cts are loaded w ith gen tam icin
w h ich is released relatively qu ickly over th e rst ew days
w ith a bu rst release directly a ter im plan tation in th e body.
In vitro stu dies sh ow ed th at m ore th an 95% o gen tam icin
w as released rom collagen f eeces w ith in th e rst 1.5 h ou rs
[45]. Th e clin ical application o th e devices is easy as th ey
can be im plan ted in to bon e an d so t tissu e with ou t di cu lty.
Th ey do n ot h ave to be rem oved becau se th ey are biodegrad-
able w ith in th e rst 8 w eeks. How ever, th e degradation
process can be associated w ith serom a orm ation w h ich is
m ost likely attribu table to th e tissu e reaction to collagen [45,
4 6 ]. In sm aller w ou n ds, th e f eece can be cu t in to sm all
pieces to redu ce th e am ou n t o th e im plan ted an tibiotic
carriers.
con text sin ce 1892 [47]. Despite th eoretical osteocon du ctive
properties, th e capability o n ew bon e orm ation by calciu m
su l ate is lim ited an d degradation produ cts m u st be con sid-
ered m ildly cytotoxic leadin g to prolon ged an d persisten t
drain age rom th e w ou n d [4 8]. Water-solu ble an tibiotics
su ch as am in oglycosides, van com ycin , daptom ycin , an d
teicoplan in are su itable an tibiotics or th e loadin g o calciu m
su l ate carriers [49 ]. A h igh ran ge o th e release kin etics o
an tibiotics rom calciu m su l ate w as reported w ith a delivery
o approxim ately 4580% o th e an tibiotic con ten t w ith in
th e rst 24 h ou rs [48].
Th ere are tw o com m ercially available produ cts w ith m edi-
cal-grade calciu m su l ate con tain in g 4% tobram ycin su l ate.
Th e pellets are 3.3 x 4.4 m m . Th ey can be u sed to ll bon e
de ects an d do n ot h ave to be rem oved. An oth er produ ct
con sists o bicon vex cylin ders w ith a diam eter o 6 m m an d
w ith a loadin g o 2.5 m g o gen tam icin per bead ( Fig 6-5 ).
Th e com bin ation o calciu m su l ate w ith n an oparticu late
h ydroxyapatite is an oth er option or a degradable an tibiotic
carrier. Th is m aterial w as sh ow n to h ave reliable release
kin etics a ter h an dloadin g o th e pellets w ith gen tam icin or
van com ycin [9]. Th e m aterial exh ibited rem arkably im proved
biocom patibility com pared to calciu m su l ate alon e. Th e
pellets are solid an d can be loaded w ith di eren t an tibiotics
accordin g to th e an tibiotic su sceptibility o th e bacteria be ore
its im plan tation .

3 .2 .3 Ca lciu m su lfa te
Resorbable bon e su bstitu te m aterials as an tibiotic carriers
are ideal or cases in w h ich in ected bon e de ects n eed to
be lled. Th ose m aterials com bin e an tibiotic-releasin g an d
osteocon du ctive properties or th e eradication o bacteria
Fig 6-5 Intraope rative use of de gradable and oste oconductive
an d su pport o n ew bon e orm ation . Calciu m su l ate an d in pe lle ts of calcium sulfate and nanoparticulate hydroxyapatite
particu lar th e h em ih ydrate (CaSO 4 0.5H2 O), com m on ly loade d with vancom ycin for the lling of a de fe ct in a tibial midshaft
kn ow n as plaster o Paris, h as been w idely u sed in th is oste omye litis.

85
 Se ct io n 1Principle s
6Local
de livery
of
antibiotics
and
antise ptics
3 .2 .4 Bio gla ss
Bioactive glasses h ave becom e o in terest in th is eld du e
to th e com bin ation o an tibacterial, osteoin du ctive, an d
an giogen ic properties w ith in on e m aterial th at does n ot
h ave to be rem oved a ter im plan tation [50 , 5 1 ].
Th e an tim icrobial e ects o bioactive glasses are m ain ly
related to th e creation o a h ostile en viron m en t or th e bac-
terial adh esion an d proli eration du e to calciu m an d sodiu m
ion s as w ell as ph osph orou s salts com bin ed w ith an in crease
o local pH an d osm otic pressu re [52].
Particu larly, th e SiO 2 , Na 2 O, CaO, P2 O 5 called BAG-S53P4
com position w as sh ow n to h ave good an tim icrobial an d n ew
bon e orm ation activity [53] an d is n ow com m ercially avail-
able as a biom aterial. Recen tly, activity again st MRSA,
Staphylococcus epidermidis, Pseudomonas aeruginosa, an d Aci-
netobacter baumanii isolates w as sh ow n or th is m aterial [54].
A ter th orou gh debridem en t o th e bon e, th e biom aterial is
sim ply in trodu ced eith er as gran u les or as pu tty in to th e
bon e de ect. A rst clin ical series on patien ts w ith ch ron ic
osteom yelitis sh ow h ealin g rates o 88.9% in 24 cases
treated w ith th e BAG-S53P4 gran u les [54].
3 .3 Co a t e d im p la n t s
Im plan ts an d all oreign bodies are pron e to bacterial adh er-
en ce, colon ization , an d su bsequ en t bio lm orm ation w h ich
are th e cru cial path oph ysiological steps in im plan t-associated
in ection s. Bio lm orm ation is o m ajor im portan ce as bac-
teria becom e em bedded w ith in th is bio lm su bstan ce. Bio-
lm is a barrier to h ost im m u n e cells an d an tibiotic th erapy
(see ch apter 1 Im plan t-associated bio lm or a detailed ex-
plan ation ). Th ere ore, th e pu rpose o im plan t coatin gs is to
preven t bacterial colon ization an d bio lm orm ation . Th ere
are di eren t strategies, eg, an tibiotic coatin gs or su r ace
m odi cation s w ith oth er an tiin ective agen ts. Tech n ologies
based on gen tam icin or silver are com m ercially available
or ractu re xation devices an d en doprosth eses.
3 .3 .1 Ge n ta m icin co a tin g fo r tib ia l n a ils
Polylactic acid (PLA)-gen tam icin coatin g is th e rst coatin g
th at h as been com m ercially available or tibial n ails [55]. Th e
in itial produ ct h as n ow been replaced by a n ew er version .
Th e PLA-gen tam icin coatin g h as a th ickn ess o approxi-
m ately 50 m w ith approxim ately 1050 g o gen tam icin
su l ate depen din g on th e size o th e n ail. In vitro stu dies
h ave sh ow n an in itial bu rst release o gen tam icin w ith in
86
th e rst m in u tes [56]. Th e coatin g can w ith stan d th e orces
du rin g in sertion o th e n ail du e to its abrasion resistan ce
an d is com pletely resorbed a ter approxim ately 6 m on th s.
Th ese gen tam icin -coated n ails are m ain ly in dicated in cas-
es w ith an in creased risk o in ection su ch as open ractu res,
revision su rgery, in patien ts w ith system ic im m u n e de -
cien cy (eg, u n con trolled diabetes, m orbid obesity), or
polytrau m a patien ts. Con train dication s are on ly related to
allergies again st gen tam icin or polylactides. Fu ch s et al [55]
h ave pu blish ed th e rst stu dy on 21 patien ts treated w ith
th e gen tam icin -coated n ail in prospective n on ran dom ized
trial w ith com plex tibial ractu res an d revision cases. Th e
u se o th is n ail sh ow ed good clin ical, laboratory, an d x-ray
ou tcom es. No im plan t-related in ection s occu rred an d n o
patien t sh ow ed an y system ic or local adverse reaction to
th e im plan t coatin g.
3 .3 .2 Silve r co a tin gs
Th e broad an tim icrobial e ect o silver h as been kn ow n or
cen tu ries an d is m ain ly related to th e availability o ree
silver ion s th at bin d to cellu lar com pon en ts su ch as en zym es
an d stru ctu ral protein s, particu larly to th eir SH-grou ps,
leadin g to altered u n ction s o th e respective m olecu les [57].
An oth er advan tage o silver is its activity again st m u ltire-
sistan t strain s su ch as MRSA, an d th at resistan ce again st
silver h as on ly rarely been reported in clin ical isolates. A
m ajor poin t or silver-coated im plan ts is to en su re biocom -
patibility as silver can be toxic to eu karyotic cells.
Com bin ed gold-silver coatin g o m egaen doprosth eses or
orth opedic tu m or su rgery h as already been reported in a
clin ical settin g. Th e gold su bstrate on top o th e titan iu m
prosth esis is in ten ded to in du ce silver release rom a 1015
m elem en tary silver overcoatin g layer [58]. In a con secu tive
case series with 20 patien ts u n dergoin g bon e tu m or resection
an d recon stru ction by m egaen doprosth eses, silver seru m
levels < 56.4 ppb w ere m easu red, w h ich is con sidered to be
n on toxic, an d n o adverse system ic even ts rom th e silver
w ere detected su ch as argyria, alth ou gh u p to 2.89 g o
silver w as u sed on th e prosth esis. In a u rth er prospective
stu dy w ith 51 patien ts with silver-coated m egaen doprosth e-
ses, in ection rates w ere reported to be 5.9% sh ow in g con -
vin cin g resu lts in th is special eld o h igh -risk su rgery [59].
An oth er tech n ology or ractu re xation devices based on
silver m icroparticles em bedded in a siloxan e-coated layer
h as already been reported in th e literatu re bu t is n ot yet
com m ercially available [60].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Volke r Alt
4 Co n clu s io n
Local treatm en t option s are o m ajor in terest or bon e an d
im plan t-associated in ection s. An tiseptics are m ain ly in -
ten ded or eradication o bacteria rom con tam in ated an d
in ected w ou n ds.
Gen tam icin , tobram ycin , an d van com ycin are th e m ost
im portan t an tibiotics or local an tibiotic treatm en t in bon e
an d im plan t in ection s. Polym eth ylm eth acrylate is th e m ost
com m on ly u sed carrier or an tibiotic-loaded beads an d
spacers. In gen eral, com m ercially available produ cts o er
th e option o m ore reprodu cible release kin etics. In com -
parison , h an dm ade im plan ts o er th e su rgeon reedom in
an tibiotic ch oice. Th e u se o PMMA-loaded beads an d spac-
ers can be con sidered to be clin ically sa e, h ow ever, dosage
recom m en dation s or th e in dividu al patien t w ith an allergic
pro le an d problem atic kidn ey u n ction sh ou ld alw ays be
con sidered. For th e Masqu elet tech n iqu e th e PMMA-loaded
an tibiotic spacer serves tw o pu rposes: th e eradication o
bacteria via th e released an tibiotic an d in du ction o a
biologically active m em bran e to acilitate u rth er bon e re-
con stru ction in a tw o-stage procedu re. Degradable carriers
su ch as collagen , calciu m su l ate, an d bioglass do n ot requ ire
rem oval. Bioglass h as osteocon du ctive properties an d is a
ller or bon e de ects a ter resection o in ected bon e rag-
m en ts. Ri am pin can n ot be u sed in com bin ation w ith PMMA
bu t can be u sed w ith degradable carriers su ch as calciu m
su l ate-h ydroxyapatite. Th ere are on ly tw o com m ercially
available an tim icrobial im plan t coatin gs available w h ich are
a PLA-gen tam icin coatin g or tibial n ails an d a silver coatin g
or m egaen doprosth eses. Th ese an d oth er coatin gs togeth er
w ith all oth er strategies in local an tibiotic treatm en t m ay
h elp to im prove ou tcom es in bon e an d im plan t-associated
in ection s in th e u tu re.
87
 Se ct io n 1Principle s
6Local
de livery
of
antibiotics
and
antise ptics
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e t a l. Con cepts or in creasin g
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e t a l. Elu tion o gen tam icin an d
van com ycin rom
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1990 Au g;61(4):353 356.
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Bioactive glass BAG-S53P4 or th e
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55. Fu ch s T, St a n ge R, Sch m id m a ie r G, e t
a l. Th e u se o gen tam icin -coated n ails
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Lack o tox icological side-e ects in
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60. Kh a lilp o u r P, La m p e K, Wa ge n e r M, e t
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Ju l;94(1):196 120.
89
 Se ct io n 1Principle s
6Local
de livery
of
antibiotics
and
antise ptics

90 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar

7 Dia gn o s tics
St p h an e Co rve c, Mara Eu ge n ia Po rtillo , Jo se p h in a A Vo sse n , An d re j Tram p u z, Pe te r J Haar

1 Ba s ics An in terdisciplin ary team is cru cial or su ccess u l bon e an d

Th e m an agem en t o prosth etic join t in ection (PJI) is o ten
gu ided by tradition , person al experien ce, an d liability aspects,
an d con sequ en tly di ers su bstan tially betw een in stitu tion s
an d cou n tries. Variou s specialists w ith di eren t poin ts o
view are in volved in th e m an agem en t o PJI, su ch as orth o-
pedic su rgeon s, in ectiou s disease specialists, an d m icrobi-
ologists. In act, n o gold stan dard de n ition o bon e an d
join t in ection exists th at is accepted by everyon e. Alth ou gh
th e de n ition s vary, a con sen su s grou p o experts rom
arou n d th e world con tribu ted to th e In tern ation al Con sen su s
Meetin g on Prosth etic Join t In ection in an attem pt to re n e
an in tern ation al con sen su s de n ition o PJI [1].
join t in ection m an agem en t. A correct diagn osis, in clu din g
th e iden ti cation o th e in ectin g m icroorgan ism (s) an d its
an tim icrobial su sceptibility rem ain s th e rst step or su c-
cess u l treatm en t ( Fig 7-1 ).
A com bin ation o laboratory, h istopath ology, m icrobiology,
an d im agin g stu dies is u su ally n ecessary to prove th e diag-
n osis o PJI ( Ta b le 7-1 ). To take advan tage o an early
an tim icrobial th erapy or to plan an appropriate su rgical
treatm en t, an accu rate preoperative diagn osis o an in ection
is essen tial.

Clinical presentation Blood markers

Radiology
(sinus tract, purulence) (CRP, ESR)

Histopathology Suspected PJI Blood cultures

Joint puncture
Preoperative
(markers and culture)

No Yes
Intraoperative

Early failure of the prosthesis 3 periprosthetic tissue cultures

(first 2 years) Sonication fluid culture (if available)
No
Vortexing culture of the prosthesis (if sonication not available)

Yes
Review clinical suspicion Pathogen identification
Yes
No

Fig 7-1 Diagnostic algorithm for prosthe tic joint infe ction. Antimicrobial susceptibility
Abbre viations: CRP, C-re active prote in; ESR, e rythrocyte New technologies
se dim e ntation rate; PJI, pe riprosthe tic joint infe ction; PCR, (eg, PCR, microcalorimetry, MALDI-TOF)
polym e rase chain re action; MALDI-TOF, m atrix-assiste d lase r Diagnosed PJI
de sorption/ ionization-tim e of ight m ass spe ctrom e try.

91
 Se ct io n 1Principle s
7Diagnostics

2 Blo o d
For th e diagn osis o bon e/ join t in ection , rou tin e periph eral
blood tests depen d on th e h osts respon se to th e in ectin g
path ogen . Th e ch aracteristics o th e m ost available seru m
in f am m atory m arkers are su m m arized in Ta b le 7-2 .
2 .1 Le u ko c yt e co u n t a n d d iffe re n t ia l
Th e blood leu kocyte cou n t or w h ite blood cell (WBC) cou n t
is typically ordered as part o rou tin e blood an alysis. Man y
problem s can resu lt in an elevated WBC cou n t. Neverth eless,
bacterial in ection s rem ain a requ en t cau se. How ever, its
sen sitivity is lim ited (45% ), alth ou gh its reported speci city
(87% ) m ay be u se u l in som e situ ation s [2]. System ic in f am -
m atory m arkers do n ot discrim in ate w h eth er an in ection
is o bacterial or u n gal origin [5].

2 .2 C-re a ct ive p ro t e in
Type o sample Diagnostic test C-reactive protein (CRP) is on e o th e m ost requ en tly u sed
Blood Leukocytes with diff, CRP, ESR, PCT, and
in f am m atory m arkers becau se it is readily available, in ex-
TNF- , IL-6, immunology pen sive, an d easy to per orm . Th e CRP level is in depen den t
Joint puncture Cell count, diff, Gram stain, arthrography, o age, sex, blood loss, or kin d o su rgery. Its u se h as been
leukocyte esterase test, culture, new su pported by th e In ectiou s Diseases Society o Am erica [6]
biomarkers ( -defensin)
an d th e Am erican Academ y o Orth opedic Su rgeon s (AAOS)
Radiology X-ray, CTscan, MRI, sonography, nuclear
[7]. How ever, alon e, th is m arker is n ot su cien tly sen sitive
medicine, PET-CTscan, scintigraphy
or speci c en ou gh to diagn ose or exclu de in ection w ith a
Intraoperative samples Culture, PCR, ESI MALDI-TOF, histology,
(eg, biopsy, synovial fluid, sonication fluid) calorimetry, antibodies, sonication h igh accu racy [8]. Th e CRP level in creases w ith in 624 h ou rs
in respon se to in f am m atory circu m stan ces an d h as a h al -li e
Ta b le 7-1 Te sts for diagnosis of prosthe tic joint infe ction. o on e day. Norm al valu es o CRP do n ot exclu de in ection ,
Abbre viations: diff, diffe re ntial; CRP, C-re active prote in; ESR,
especially in case o low -grade in ection s. Moreover, CRP
e rythrocyte se dim e ntation rate; PCT, procalcitonin; TNF- , tum or
ne crosis factor- ; IL-6 , inte rle ukin-6; CT, com pute d tom ography; MRI, levels are in creased n orm ally a ter su rgery (peak a ter 34
m agne tic re sonance im aging; PET-CT, positron-e m ission tom ography days), ref ect postin terven tion in f am m ation , an d are lim ited
com pute d tom ography; PCR, polym e rase chain re action; ESI, by u n derlyin g in f am m atory diseases. Th ere ore, serial post-
e le ctrospray ionization tim e of ight; MALDI-TOF, m atrix-assiste d lase r operative m easu rem en ts are essen tial or accu rate in terpre-
de sorption/ ionization-tim e of ight m ass spe ctrom e try.
tation rath er th an a sin gle valu e [9]. C-reactive protein h as
a sligh tly better sen sitivity an d speci city th an eryth rocyte
sedim en tation rate (ESR) [2, 10].

2 .3 Er yt h ro c yt e s e d im e n t a t io n ra t e
Togeth er w ith CRP, ESR is on e o th e m ost u sed in f am m a-
Marker Cut-o Sensitivity Specif city Re erences tory m arkers. How ever, ESR h as n eith er en ou gh sen sitivity
(%) (%)
n or speci city to correctly detect PJI. Fu rth erm ore, ESR
WBC 11,000 x 109 cells/L 45 87 [2]
levels are also in creased n orm ally a ter su rgery. Moreover,
CRP 10 mg/L 88 74 [2]
it is recogn ized th at determ in ation s o ESR an d CRP levels
ESR 30 mm/h 75 70 [2]
are less accu rate or sh ou lder th an or h ip or kn ee arth ro-
PCT 0.3 ng/mL 33 98 [3] plasty in ection s [11]. Receiver operatin g ch aracteristic cu rves
TNF- 40 ng/mL 43 97 [3,4] w ere di eren t betw een ESR an d CRP an alyzin g early versu s
IL-6 10 pg/mL 97 91 [2] late ch ron ic in ection s [12]. Th is observation m ay be related
to th e h igh er proportion o Propionibacterium acnes in ection s
Ta b le 7-2 Se rum in am matory m arke rs for the diagnosis of
prosthe tic joint infe ction.
in sh ou lder in ection s, ref ectin g th at n orm al valu es o CRP
Abbre viations: WBC, white blood ce ll count; CRP, C-re active prote in; an d/ or ESR levels do n ot exclu de low -grade in ection s [13].
ESR, e rythrocyte se dim e ntation rate; PCT, procalcitonin; TNF- , Th ere ore, a n u m ber o au th ors con sider ESR as obsolete
tum or ne crosis factor- ; IL-6 , inte rle ukin-6 . or diagn osin g PJI [2, 14].

92 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar
2 .4 Pro ca lcit o n in a n d t u m o r n e cro s is fa ct o r-
Procalciton in (PCT) determ in ation in blood h as been sh ow n
to be u se u l in oth er in ection s bu t h as been stu died in on ly
a sm all n u m ber o patien ts or diagn osis o PJI. It seem s
th at seru m PCT level is speci ic (98% ) bu t n ot sen sitive
(33% ) [3 ]. How ever, CRP com bin ed w ith PCT leads to 83%
sen sitivity an d 83% speci icity revealin g a positive predic-
tive valu e an d a n egative predictive valu e o 89% an d 74% ,
respectively [1 0 ]. At a cu t-o level o 0.4 n g/ m L, PCT seem s
to be a sen sitive an d speci ic m arker in th e diagn osis o
septic arth ritis an d acu te osteom yelitis [1 5 ]. Accordin g to
a recen t system atic review an d m etaan alysis, PCT m ay be
m ore su itable as an aid or ru le-in diagn osis rath er th an
or exclu sion o septic arth ritis or osteom yelitis an d th e
u se o a low er cu t-o valu e m ay im prove its diagn ostic
per orm an ce [1 6 ].
Tu m or n ecrosis actor (TNF)- is elevated in patien ts w ith
osteolysis com pared to m atch ed con trols. Th e role o TNF-
an d its poten tial as a target o n on su rgical th erapy to preven t
osteolysis warran t u rth er in vestigation in larger, prospective
stu dies [17]. Patien ts th at h ad cem en ted im plan ts h ave sig-
n i can tly h igh er levels o TNF- th an patien ts w ith cem en t-
less varieties (P = .042) [18 ]. Fu rth er stu dies are n eeded to
dem on strate th e real advan tage o th is n ew m arker in PJI
an d in ection .
2 .5 In t e rle u k in - 6
In terleu kin -6 (IL-6) is produ ced by m acroph ages an d
stim u lated m on ocytes. Mon ocytes can also respon d to poly-
eth ylen e particles by secretin g IL-6 bu t h igh con cen tration s
o IL-6 h ave also been detected in th e in ter ace m em bran e
su rrou n din g loosen ed im plan ts [18, 19]. In terleu kin -6 retu rn s
to baselin e level as early as a ew h ou rs postoperatively
du rin g h ealin g processes leadin g to n orm al valu e a ter an
arth roplasty in 23 days, m akin g it a u se u l m arker or
early postoperative PJI [20]. A recen t system atic review an d
m etaan alysis dem on strates th at IL-6 an d CRP h ad a sig-
n i can tly h igh er diagn ostic odds ratio th an th e leu kocyte
cou n t an d ESR or discrim in atin g in ectiou s rom n on in ec-
tiou s cau ses in revision arth roplasty [2 ]. Despite th ese
th eoretical advan tages, given th e lack o con sisten t data an d
th at it is less available an d m ore expen sive th an oth er
in f am m atory m arkers, th e IL-6 test is n ot, at presen t, part
o stan dard clin ical practice.
To su m m arize, a system atic review an d m etaan alysis w as
per orm ed in 2010 on in f am m atory blood laboratory levels
as m arkers or PJI bu t as w ith an y blood biom arkers, it m u st
be rem em bered th at an in ection m ay be presen t even i th e
valu es are n orm al [2]. Addition al diagn ostic tools m u st be
developed in th e u tu re.
2 .6 Im m u n o lo g y
Staphylococcus aureus rem ain s th e leadin g m icroorgan ism
respon sible or PJI an d im plan t-associated in ection s.
Staph ylococcal in ection s can be ch allen gin g to diagn ose
or m an y reason s (eg, n egative cu ltu re, an tibiotic treatm en t,
or sm all-colon y varian t), an d th ere is n o clin ically available
diagn ostic test or h ost im m u n ity. A cost-e ective assay or
determ in in g th e an tiglu cosam in idase titer, w h ich can be
readily com bin ed w ith con ven tion al serology to im prove
diagn osis an d to assess h ost im m u n ity again st S aureus h as
been developed [2 1 ]. Like or oth er biom arkers, u rth er
stu dies on im m u n ology, seru m m arkers, an d in f am m ation
disequ ilibriu m are n eeded to better u n derstan d th e role an d
th e im pact on th e osteogen esis du rin g an im plan t-associated
in ection lin ked to low con cen tration s o m etal particles.
For exam ple, th e role o leptin in bon e an d cartilage u n ction
an d its im plication in in f am m atory an d degen erative join t
diseases h ave been recen tly reported. Leptin is an adipokin e
w ith pleiotropic action s th at regu lates ood in take, en ergy
m etabolism , in f am m ation , an d im m u n ity, an d also par-
ticipates in th e com plex m ech an ism th at regu lates skeleton
biology, both at bon e an d cartilage level [22].
2 .7 Ou t lo o k o n b lo o d m a rke rs
Mu ltidisciplin ary team s in volved in PJI m an agem en t per orm
a w ide spectru m o tests in an attem pt to diagn ose PJI [23],
in clu din g:
Local m easu res o syn ovial in f am m ation : syn ovial
f u id WBC cou n t an d di eren tial, syn ovial tissu e
h istology
System ic m easu res o in f am m ation : seru m CRP level,
ESR, IL-6
Radiograph ic tests: x-rays, bon e scan , m agn etic
reson an ce im agin g, com pu ted tom ograph y, positron -
em ission tom ograph y
Bacterial isolation tech n iqu es: Gram stain , cu ltu re
93
 Se ct io n 1Principle s
7Diagnostics
Facin g th e ch allen ge o accu rately diagn osin g in ection ,
despite th e lack o a clear de n ition o PJI/ im plan t-associated
in ection w ith di eren t criteria, several societies, su ch as
In ectiou s Diseases Society o Am erica [6], th e Mu scu loskel-
etal In ection Society [7] an d in Fran ce La Socit de Pathologie
In ectieuse de Langue Franaise (SPILF) [24], recen tly pu blish ed
di eren t de n ition s o PJI u sin g a com bin ation o clin ical
data an d six o th e above tests. Recen tly, a revival o bio-
m arkers h as occu rred. Th ere ore, a recen t stu dy ch ose to
screen 43 biom arkers th at dem on strated an elevation in th e
settin g o PJI an d cou ld poten tially be diagn ostic or PJI
( Ta b le 7-3 ). Am on g th em , 16 evalu ated biom arkers dem on -
strated th e greatest an d m ost con sisten t elevation s in th e
screen in g process: h u m an -de en sin 13 ( -de en sin ),
IL-1a, IL-1, IL-6, IL-8, IL-10, IL-17, gran u locyte colon y-
stim u latin g actor (G-CSF), vascu lar en doth elial grow th
actor (VEGF), CRP, n eu troph il elastase 2 (ELA-2), lacto errin ,
n eu troph il gelatin ase-associated lipocalin (NGAL), resistin ,
th rom bospon din , an d bactericidal/ perm eability-in creasin g
protein (BPI). On ly ve biom arkers, in clu din g h u m an
-de en sin 1-3, n eu troph il elastase 2, bactericidal/ perm ea-
bility-in creasin g protein , n eu troph il gelatin ase-associated
lipocalin , an d lacto errin , correctly predicted th e Mu scu lo-
skeletal In ection Society classi cation o all patien ts, w ith
100% sen sitivity an d speci city or th e diagn osis o PJI.
Despite th e act th at on ly a lim ited n u m ber o patien ts (46)
w ere in clu ded, th e last stu dy reveals th at th e syn ovial f u id
-de en sin im m u n oassay correctly predicted th e Mu scu lo-
skeletal In ection Societys classi ication o all patien ts,
dem on stratin g a sen sitivity an d speci city o 100% or th e
diagn osis o PJI [25].
Native Prosthetic joints
joints
Normal Septic PJI
arthritis
Leukocytes (x109/L) < 0.2 > 50 > 1.7 (knee), > 4.2 (hip)
Neutrophils (%) < 25 > 90 > 65 (knee), > 80 (hip)
Ta b le 7-3 Cut-off value s for the diagnosis of prosthe tic joint
infe ction com pare d with se ptic arthritis.
Abbre viation: PJI, prosthe tic joint infe ction.
94
3 Jo in t p u n ct u re
3 .1 Ho w t o p e r fo rm jo in t p u n ct u re
Arth rocen tesis, ie, syn ovial f u id aspiration , can be per orm ed
eith er diagn ostically or th erapeu tically on n ative or pros-
th etic join ts. Wh ereas th e syn ovial f u id aspiration o a kn ee
is easy to per orm in th e o ce, th e aspiration o a h ip ar-
th roplasty requ en tly requ ires u ltrasou n d or radiograph ic
gu idan ce. Neverth eless, especially w h en per orm ed preop-
eratively, th is type o sam plin g requ ires m axim u m care to
avoid con tam in ation eith er o th e sam ple or th e join t itsel .
Syn ovial f u id is u su ally sen t or cell cou n t, di eren tiation ,
an d m icrobiological cu ltu re. Fu rth erm ore, in f am m atory
m arkers m ay also be in vestigated alth ou gh cu rren tly th ey
are n ot w idely u sed.
3 .2 Ce ll co u n t , d iffe re n t ia t io n , Gra m s t a in t e s t
Th e detection o leu kocytes in th e syn ovial f u id, ie, cell
cou n t an d di eren tial, is an e ective an d sim ple w ay to
distin gu ish betw een PJI an d aseptic ailu re. Despite cu t-o
valu es or positive tests bein g sim ilar alth ou gh n ot equ al in
di eren t stu dy popu lation s an d di eren t join t types, gu ide-
lin es do n ot in clu de a speci c cu t-o valu e in th eir diagn ostic
criteria [6 , 2 6 ]. It is sign i can t th at th e cu t-o valu es or
diagn osin g PJI are con siderably low er th an th e on es or
septic arth ritis in n ative join ts ( Ta b le 7-3 ). Th e optim al cu t-o
valu es appear to be h igh er in h ip th an in kn ee arth roplasties,
probably related to th e h igh er requ en cy o S aureus in ec-
tion s in h ip PJI, ref ectin g th at in ection s cau sed by h igh ly
viru len t m icroorgan ism s are associated w ith a h igh er total
leu kocyte cou n t [27]. In th e m ajority o th ese stu dies, patien ts
with in f am m atory diseases were exclu ded. For th ese patien ts,
a h igh er baselin e n u cleated cell cou n t w ou ld be expected,
an d accordin gly, th e cu t-o valu es m en tion ed above w ou ld
Re erences be expected to be less speci c [1]. In con trast to prosth etic
join ts, th ere are n o precisely de n ed th resh olds or n ative
join ts becau se th e cell cou n t alon e does n ot provide su cien t
eviden ce o an in ection . Th ere ore, it is u su ally n ecessary
[27, 33]
[27, 33] to w ait or th e bacteriology resu lts or an accu rate diagn osis
(> 10 days). In th e presen ce o a h igh leu kocyte cou n t,
u rgen t su rgical in terven tion m ay be u n dertaken prior to a
de n itive diagn osis.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar
For determ in ation o leu kocyte cou n t an d di eren tial, vials
sh ou ld con tain eth ylen e-diam in e-tetraacetic acid (EDTA),
citrate, or h eparin to preven t coagu lation o th e aspirate.
Th e cell cou n t can be determ in ed by au tom ated h em atology
or by m an u al cell cou n ters. Metal-on -m etal h ip arth roplasties
can give a alsely elevated syn ovial f u id cell cou n t w h en
u sin g au tom ated cell cou n ters. Th is can be overcom e by
m an u ally cou n tin g cell cou n ters. Im portan tly, th e n eu troph il
percen tage rem ain s accu rate or th is grou p o patien ts, given
th at it is determ in ed m an u ally [1]. Clotted specim en s are
treated be ore an alysis w ith h yalu ron idase or 10 m in u tes
at room tem peratu re.
Addition al tests in syn ovial f u id, su ch as glu cose, lactate,
or CRP h ave n ot been sh ow n to brin g addition al in orm ation
regardin g th e diagn osis o in ection [28 31 ].
Crystal an alysis provides in orm ation abou t crystal-in du ced
arth ropath y. Th e gross appearan ce o syn ovial f u id can
provide u se u l diagn ostic in orm ation in term s o th e degree
o join t in f am m ation an d presen ce o h em arth rosis. Micro-
biological stu dies o syn ovial f u id are th e key test to provide
con rm ation o an in ectiou s con dition . Join t in f am m ation
is associated w ith in creased syn ovial f u id volu m e, redu ced
viscosity, in creasin g tu rbidity an d cell cou n t, an d in creasin g
ratio o polym orph on u clear to m on on u clear cells, bu t su ch
ch an ges are n on speci c an d m u st be in terpreted in th e
clin ical settin g. How ever, detection o syn ovial f u id m on o-
sodiu m u rate an d calciu m pyroph osph ate dih ydrate crystals,
even rom u n in f am ed join ts du rin g clin ically qu iet periods,
allow s a precise diagn osis o gou t an d calciu m pyroph osph ate
crystal-related arth ritis [32].
On e aliqu ot o n ative f u id sh ou ld be con served or direct
m icroscopic Gram stain exam in ation . Direct bacteriological
exam in ation a ter Gram stain can visu alize bacteria, espe-
cially a ter a cytocen tri u gation step an d in vestigation o th e
pellet. Th e speci city o Gram stain is h igh (u p to 97% ) bu t
it h as poor sen sitivity (< 25% ) [27, 34, 35]. Th ere ore, Gram
stain in g is n ot rou tin ely recom m en ded [36].
3 .3 Ar t h ro gra p h y
Im agin g u sin g con trast agen t adm in istered on ce th e pu n ctu re
is com plete via th e in situ n eedle is especially u se u l in th e
case o prosth etic h ip join ts. It reveals protru sion s rom th e
join t cavity, abscess cavities, an d stu lou s tracts, even i n o
extern al stu la is visible. Th ese sign s are o ten criteria or
tw o-stage revision . Im proved resolu tion th rou gh digital
su btraction tech n iqu e is possible. In 2005, a m etaan alysis
ou n d th at th e su btraction arth rograph y w as a sen sitive
tech n iqu e or detection o loosen in g o total h ip prosth esis,
o erin g added valu e over con trast arth rograph y, especially
or evalu ation o th e em oral com pon en t [37].
3 .4 Le u ko c yt e e s t e ra s e t e s t
Leu kocyte esterase is an en zym e presen t in n eu troph ils,
w h ich is requ en tly m easu red by a colorim etric strip to
determ in e pyu ria or th e diagn osis o u rin ary tract in ection
( Fig 7-2 ). Th is test strip h as recen tly been tested in tw o stu d-
ies in syn ovial f u id to evalu ate PJI [38, 39]. Lim itation s o
th is test are th at it is sem iqu an titative (resu lts are read by
com parison w ith colors prin ted on th e produ ct label w ith a
color ast prin tin g m eth od colorim etric) an d th at presen ce
o blood in syn ovial f u id m ay prom ote alse-positive resu lts.
In act, in on e o th ese stu dies, patien ts w ith excessive blood
in syn ovial f u ids (10% ) were exclu ded [38] an d in th e oth er
stu dy, alm ost 30% o th e tests w ere n ot valid becau se th ey
w ere u n readable du e to blood, debris, or w ere in determ in ate
resu lts [22].
Le u ko cyt e s
6 0 120 s e co n d s
Ne g. Trace + ++
Fig 7-2 Le ukocyte e ste rase strip te st re sults.
95
 Se ct io n 1Principle s
7Diagnostics
3 .5 Ou t lo o k o n m a rke rs
Oth er m arkers, in clu din g th ose u sed in blood, sh ow som e
prom ise or th e diagn osis o PJI. C-reactive protein deter-
m in ation in syn ovial lu id appears to h ave a sen sitivity
ran gin g rom 85 to 87% , bu t th e speci cities varied w idely
[14, 30, 40].
Determ in ation o syn ovial f u id IL-6 levels sh ow ed h igh
speci city (93100% ) bu t variable sen sitivity (69100% )
an d speci city [14, 40, 41]. A recen t stu dy also in vestigated
th e valu e o PCT in syn ovial f u id, an d au th ors con clu ded
th at th is m arker h ad a h igh n egative predictive valu e th at
cou ld exclu de in ection in both n ative an d prosth etic join ts.
How ever, on ly 14 su bjects w ith PJI w ere in clu ded [42]. Th ere-
ore, u rth er stu dies are n eeded to con rm th ese n din gs.
Oth er in terleu kin s, su ch as in terleu kin -1 (IL-1 ) h ave
been stu died in syn ovial f u id. Its sen sitivity an d speci city
w ere low er th an or IL-6 [40]. Recen tly, th e role o an tim i-
crobial peptides, su ch as - an d -de en sin s, h as been assessed.
Cells o th e im m u n e system con tain th ese peptides to assist
in killin g ph agocytized bacteria an d alm ost all epith elial cells.
Most de en sin s u n ction by bin din g to th e m icrobial cell
m em bran e an d, on ce em bedded, orm in g pore-like m em bran e
de ects th at allow e f u x o essen tial ion s an d n u trien ts. Th is
stu dy sh ow ed prom isin g resu lts bu t on ly 15 patien ts w ith
staph ylococcal PJI w ere in clu ded [4]. Cu rren tly, th ese n ew
biom arkers m ay be con sidered as prom isin g tools or diag-
n osis or ollow -u p, bu t robu st data are still m issin g, an d
u n til u rth er data becom e available an d costs redu ced, a
recom m en dation or clin ical u se can n ot be m ade [1].
96
3 .6 Cu lt u re -n e ga t ive in fe ct io n
Cu ltu re o preoperative syn ovial f u id is priceless or early
iden ti cation o th e in ectin g path ogen an d determ in ation
o an tim icrobial su sceptibility. Alth ou gh som e su rgeon s in -
ocu late th e aspirated f u id obtain ed by arth rocen tesis at th e
tim e o collection in to blood-bottle cu ltu re, an aliqu ot o
aspirated syn ovial f u id sh ou ld be con served an d sen t to th e
m icrobiology laboratories or cell cou n t, di eren tiation , an d
con ven tion al cu ltu res on agar plates an d en rich m en t broth .
Sen sitivity o aspirated f u id cu ltu re is betw een 65100%
an d m ay be u rth er im proved by in ocu lation in to blood-
cu ltu re bottles [4 3 , 4 4 ]. Widely varied sen sitivity m ay be
related to low -grade m icroorgan ism -related in ection or
an tim icrobial treatm en t prior to arth rocen tesis, w h ere
sen sitivity is low er i patien ts received an tibiotics 23 w eeks
prior to aspiration [4 5 4 7 ], an d type o in ection , w h ere
sen sitivity is h igh er in acu te in ection s. Th is m ay be du e
also to th e viru len ce o th e path ogen [4 6 ]. Neverth eless,
prolon ged cu ltu res are alw ays recom m en ded to avoid a alse-
n egative cu ltu re. Th ere ore, an tibiotics sh ou ld be stopped
at least 2 w eeks prior to aspiration w h en ever possible,
syn ovial lu id sh ou ld be in ocu lated directly in to blood-
cu ltu re bottles, an d an aliqu ot o n ative syn ovial f u id sh ou ld
be plated. To redu ce th e rate o cu ltu re-n egative in ection ,
aerobic agar plates sh ou ld be in cu bated at least 57 days
an d an aerobic agar plates at least 10 days to detect slow er
grow in g m icroorgan ism s, su ch as sm all-colon y varian ts or
an aerobic organ ism s [4 8 ]. In act, in a recen t stu dy, alse-
n egative rates o preoperative aspiration relative to in tra-
operative cu ltu re w ere 56% an d 46% in h ip an d kn ee PJI,
respectively, w ith discordan ce rates o 25% an d 21.4% ,
respectively. Rates o n egative in traoperative cu ltu res w ere
15% in h ip PJI an d 20.7% in kn ee PJI [49].
Today, accu rate prean alytical con dition s or preoperative,
in traoperative, or postoperative sam plin g are n ecessary to
isolate th e in ectin g m icroorgan ism in PJI. Several tech n iqu es
w ill be discu ssed in topic 5.2 o th is ch apter.
For oth er im plan t-associated in ection s, aspiration o th e
im plan t area can be per orm ed w ith u ltrasou n d gu idan ce
as n eeded to obtain f u id. Flu id sh ou ld be cu ltu red as de-
scribed above, an d i possible, a cell cou n t per orm ed or
diagn osis.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar
4 Ra d io lo g y o f m u s cu lo s ke le t a l in fe ct io n
4 .1 In t ro d u ct io n
Early diagn osis o m u scu loskeletal in ection is im perative
to in itiate tim ely treatm en t an d preven t poten tial com plica-
tion s. Mu scu loskeletal im agin g is an essen tial diagn ostic
tool n eeded by ph ysician s to diagn ose m u scu loskeletal
con dition s in clu din g in ection . Baselin e stu dies sh ou ld in -
clu de at a m in im u m plain x-ray exam in ation s. Th ese x-ray
exam in ation s are h elp u l to detect su btle ch an ges over tim e.
Becau se each im agin g m odality h as speci c stren gth s an d
lim itation s, a m u ltim odality approach is com m on ly u sed.
Th is part o th e ch apter w ill h elp to de n e w h ich radio-
logical stu dies are ben e cial to clin ician s an d su rgeon s in
diagn osin g m u scu loskeletal in ection an d ollow in g progress
o treatm en t. In th is part o th e ch apter, n u m erou s m edical
im ages rom varied clin ical scen arios w ill be u sed to illu strate
advan tages an d disadvan tages o each m odality. In cases o
m u scu loskeletal in ection , th e radiologist is an im portan t
m em ber o th e patien t care team , alon g w ith th e in ectiou s
disease ph ysician an d su rgeon . Treatin g ph ysician s sh ou ld
con er w ith th e radiologist to determ in e th e m ost appropri-
ate exam in ation s to requ est so as to provide appropriate
diagn osis an d treatm en t in orm ation th at w ill best acilitate
patien t care.
4 .2 St a n d a rd x-ra y
Con ven tion al x-rays are o ten th e in itial im agin g exam in ation
obtain ed an d can be h elp u l in su ggestin g th e correct diag-
n osis an d to exclu de oth er etiologies, su ch as tu m or or
trau m a. Plain x-ray is o ten in sen sitive du rin g th e early
stages o bon e in ection sin ce at least 3050% o bon e n eeds
to be destroyed be ore abn orm alities are seen on x-rays [50 ,
51]. In itial su btle radiograph ic n din gs in clu de ocal so t-tissu e
sw ellin g, periosteal elevation or th icken in g, osteopen ia, an d
osteolysis ( Fig 7-3 , Fig 7-4 ). Du rin g th e su bacu te or ch ron ic
stage o osteom yelitis, radiograph ic n din gs can in clu de a
radiolu cen t abscess, sequ estru m , ie, dead sclerotic bon e;
in volu cru m , ie, periosteal n ew bon e su rrou n din g a sequ estru m ;
an d sin u s tracts ( Fig 7-5 ). Organ ization in th e in tram edu llary
space o a cystic cavity represen ts an in traosseou s abscess
or Brodie' s abscess ( Fig 7-6 ). In patien ts w ith orth opedic
im plan ts, in ection can be seen as im plan t loosen in g w ith
or w ith ou t path ological ractu res or dislocation ( Fig 7-7 ,
Fig 7-8 , Fig 7-9 ). Th ese radiograph ic n din gs are o ten sim ilar
to th ose seen in aseptic loosen in g, an d th e diagn osis is based
on a com bin ation o h istory, laboratory valu es, an d aspira-
tion o periprosth etic f u id.
Septic arth ritis is a m edical em ergen cy associated w ith a
sign i can t m orbidity an d n eeds u rgen t diagn osis an d m an -
agem en t. X-rays m ay sh ow periarticu lar osteopen ia, e u sion ,
so t-tissu e sw ellin g, an d loss o join t space. Progression o
th e in ection can cau se erosion s, periosteal reaction , join t
m alalign m en t, an d an kylosis.
97
 Se ct io n 1Principle s
7Diagnostics
a b
Fig 7-3 a b Foot infe ction in a 6 3 -ye ar-old woman with diabe te s
m e llitus.
a Initial x-ray shows soft-tissue swe lling at the m e dial aspe ct of
the rst m e tatarsal he ad (arrow).
b X-ray 4 we e ks late r de m onstrate s soft-tissue de fe ct, oste olysis,
oste oscle rosis, and fragm e ntation. Radioluce nt are as within the
soft tissue s are re late d to the pre se nce of gas (arrow).
a b
Fig 7-5 a b He e l ulce r and se que strum form ation in a 35 -ye ar-old
im munocomprom ise d wom an.
a X-ray re ve als a large he e l ulce r with unde rlying osse ous
e rosions.
b Subse que nt x-ray with a large se que strum (arrows).
98
a b
Fig 7-4 a b Pe rioste al re action in a 24 -ye ar-old m an with
m e thicillin-re sistant Sta phylococcus a ure us infe ction of the fe m ur.
a Initial x-ray de m onstrate s pe rioste al re action (arrows).
b X-ray 3 we e ks late r shows incre asing pe rioste al re action and
e rosion of cortical bone .
Fig 7-6 A 15 -ye ar-old boy with
Brodie s absce ss. AP x-ray of
the tibia shows an e longate d
radioluce nt le sion (arrows).
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar

a b
Fig 7-7 Exte nsive posttraum atic Fig 7-8 a b Long-ste m custom fe m oral prosthe sis in a 42-ye ar-old
and postsurgical change s m an afte r oste osarcom a re se ction.
including an intram e dullary a Initial x-ray with prosthe sis in good position.
rod and distal inte rlocking b Follow-up im aging de m onstrate s loose ning of the prosthe sis
scre ws in the le ft fe m ur. with associate d pe rioste al re action. The diagnosis of infe ction
Luce ncy surrounding the scre ws was made base d on the com bination of history, laboratory
and m otion of the scre ws is value s, and aspiration of pe riprosthe tic uid. Subse que nt
se e n. Subse que nt surge ry surge ry con rm e d prosthe tic joint infe ction.
de m onstrate d im plant-associate d
infe ction.

Fig 7-9 A 53 -ye ar-old m an with

drainage and pain at the site of
the plate and scre w construct.
The hardware was re m ove d. X-ray
shows e nlarge d scre w tracts and
pe riostitis (arrows), com patible
with the ope rative diagnosis of
im plant-associate d infe ction.

99
 Se ct io n 1Principle s
7Diagnostics
4 .3 Co m p u t e d t o m o gra p h y
Com pu ted tom ograph ic (CT) im agin g provides good spatial
an d con trast resolu tion o bon e an d su rrou n din g so t tissu e.
Th e m ajor u se o in traven ou s con trast du rin g CT exam in ation
is to dem on strate th e exten t o th e in ection , localize so t-
tissu e ch an ges, an d determ in e in volvem en t o su rrou n din g
ascial com partm en ts. Addition ally, CT is th e m odality o
ch oice or th e detection o gas in th e so t tissu e an d osseou s
stru ctu res [5 2]. Com pu ted tom ograph ic eatu res o acu te
osteom yelitis in clu de in creased den sity o th e n orm al atty
m edu llary can al as it is replaced by in ectiou s edem a, blu rrin g
o at plan es, an d periosteal reaction [53 ]. In patien ts w ith
ch ron ic in ection , CT im agin g can dem on strate abn orm al
th icken in g o th e a ected cortical bon e, en croach m en t o
th e m edu llary cavity, sequ estru m orm ation an d ch ron ic
drain in g sin u s ( Fig 7-10 ) [54], [55]. Com pu ted tom ograph y is
an im portan t m odality in gu idin g biopsies, in evalu atin g th e
n eed or su rgery, an d in plan n in g th e su rgical approach .
4 .4 Ma gn e t ic re s o n a n ce im a gin g
Magn etic reson an ce im agin g (MRI) is u se u l or m an y aspects
o diagn osis an d treatm en t plan n in g in m u scu loskeletal
in ection . Th e h igh spatial resolu tion h as th e ability to
delin eate th e exten t o th e in ection , evalu ate or abscess
cavity orm ation , an d plan treatm en t. Magn etic reson an ce
im agin g is h igh ly sen sitive or detectin g osteom yelitis as
early as 35 days ( Fig 7-11 , Fig 7-12 , Fig 7-13 ). In th e acu te
a b
Fig 7-10a c A 47-ye ar-old man with a history of distal tibial and bular fracture s, ope n re duction and
inte rnal xation, and subse que nt re m oval of infe cte d hardware .
a X-ray de m onstrate s e xte nsive posttraumatic and postsurgical change s as we ll as pe rioste al thicke ning.
b c Axial compute d tomographic image s demonstrate a se que strum (arrow) and a sinus tract (arrowhe ads).
100
ph ase o osteom yelitis, th e edem a an d exu dates w ith in th e
m edu llary space produ ce a decreased sign al on th e T1-
w eigh ted im ages an d an in creased sign al on T2-weigh ted an d
in version recovery sequ en ces. O ten th e su rrou n din g so t
tissu es are also abn orm al, an d o ten th e tract o th e skin
u lcer can be ollow ed to th e bon e. Th e cortical bon e m ay
be disru pted an d can h ave abn orm ally in creased sign al in -
ten sity. Cortical th icken in g can be seen in ch ron ic in ection
o bon e bu t is absen t in th e acu te ph ase. Th e u se o gado-
lin iu m en h an cem en t can aid in iden ti yin g sin u s tracts an d
distin gu ish in g cellu litis rom abscess [5 6 ]. Osteom yelitis
sh ou ld n ot be con u sed w ith reactive m arrow ch an ges sec-
on dary to an adjacen t in ection . On T2-w eigh ted im ages,
reactive m arrow appears as h yperin ten se m arrow . On T1-
w eigh ted im ages th ere is n o low sign al th at illu strates
osteom yelitis [57 ].
An in creasin g n u m ber o join t replacem en ts are bein g
per orm ed to deal w ith th e agin g popu lation . Th e u se o
MRI in patien ts w ith m etallic im plan ts is lim ited by th e
presen ce o arti acts, w h ich can obscu re sign s o in ection .
Stan dard MRI tech n iqu es to redu ce m etal arti act in clu de
scan n in g on a low er eld stren gth m agn et, an d u sin g h igh
ban dw idth param eters, sm aller voxel size, an d appropriate
sequ en ces. Advan ced MRI tech n iqu es to u rth er redu ce
m etal arti act in clu de th e u se o specialized sequ en ces, su ch
as slice-en codin g or m etal arti act correction (SEMAC), an d
m u ltiacqu isition variable-reson an ce im age com bin ation
(MAVRIC). Th e u se o th ese m etal arti act su ppression
algorith m s in patien ts w ith h ardw are an d su spected in ec-
tion can im prove th e qu ality o im ages [5 8]. Speci c MRI
sequ en ces to order as w ell as th e poten tial n eed or con trast
m aterial sh ou ld be discu ssed in advan ce w ith th e radiologist
to im prove th e yield o th is im agin g m odality.
c
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar

a b c d
Fig 7-11a d He e l ulce r and oste omye litis in a 42-ye ar-old paraple gic m an.
a Late ral x-ray de m onstrate s loss of he e l soft tissue and scle rosis of the unde rlying calcane us.
b d Sagittal T1-we ighte d (re pe tition tim e ( TR)/ e cho tim e ( TE) TR/ TE = 719/ 9.9 m s), uid-atte nuate d inve rsion re cove ry-we ighte d ( TR/ TE/
TI = 6 78 3/ 28/ 130 m s) and postgadolinium ( TR/ TE = 812 / 9.9 m s) m agne tic re sonance im age s show abnormal ill-de ne d de cre ase d T1
and incre ase d uid-atte nuate d inve rsion re cove ry (FLAIR) signal in the poste rior calcane us. Enhance m e nt on postcontrast image s is se e n
in this are a. Subse que nt surge ry con rm e d oste omye litis.

b c

a d e f
Fig 7-12a f A 61-ye ar-old wom an with diabe tic foot ulce r.
a X-ray de m onstrate s juxtaarticular oste oporosis, se ve re narrowing of the joint space due to cartilage dam age and de struction of the
subchondral bone on both side s of the rst m e tatarsophale nge al joint. Adjace nt soft-tissue swe lling is also se e n.
b e Coronal T1-we ighte d ( TR/ TE = 615/ 11 m s), fat-suppre sse d T2-we ighte d ( TR/ TE = 3821/ 4 6 m s), and pre - and postgadolinium ( TR/ TE =
6 30/ 11 m s) m agne tic re sonance im age s show abnormal ill-de ne d de cre ase d T1 and incre ase d T2 signal in the rst m e tatarsal he ad and
proxim al phalanx at the m e tatarsophalange al joint. Enhance m e nt on postcontrast im age s is pre se nt in this are a.
f Axial and postgadolinium im age de m onstrate s involve m e nt of the rst m e tatarsophalange al joint with osse ous de struction, com patible
with se ptic arthritis. Exte nsive soft-tissue swe lling surrounds the joint with a small uid colle ction suspicious for absce ss. Se ptic arthritis
in the diabe tic foot is typically a re sult of dire ct spre ad from adjace nt bone or soft-tissue infe ction.

101
 Se ct io n 1Principle s
7Diagnostics

a b c

d e f g
Fig 7-13 a g Me thicillin-re sistant Sta phylococcus a ure us oste om ye litis in a 47-ye ar-old wom an.
a X-ray shows pe rioste al re action and cortical irre gularity along the m e dial aspe ct of the proxim al fe m ur (arrows).
b c Coronal T1-we ighte d ( TR/ TE = 717/ 14 m s) and uid-atte nuate d inve rsion re cove ry-we ighte d ( TR/ TE/ TI = 4 6 0 0/ 55/ 145 m s) m agne tic
re sonance im age s show abnormal de cre ase d T1 and incre ase d T2 signal within the m e dullary cavity. Surrounding e de m a is also in the
surrounding soft tissue s.
d g Axial T1-we ighte d ( TR/ TE = 517/ 8 ms), fat-suppre sse d T2-we ighte d ( TR/ TE = 330 0/ 6 0 ms), pre - and postgadolinium ( TR/ TE = 58 3/ 8 ms)
magne tic re sonance image s de monstrate abnormal de cre ase d T1 and incre ase d T2 signal as well as e nhance me nt on postcontrast image s.

102 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar

4 .5 So n o gra p h y cally n oted to be h igh or th ese stu dies; h ow ever, th e

Son ograph y is a u se u l tech n iqu e or in ection diagn osis. In
particu lar, son ograph y can be u sed to determ in e size, exten t,
an d location o abscess cavities or f u id collection s. Pow er
Doppler son ograph y can sh ow in creased vascu latu re an d
h yperem ia in th e w all o abscesses. Addition ally, son ograph y
can di eren tiate in ection rom oth er path ological con dition s
w ith a sim ilar clin ical presen tation . Fu rth erm ore, in region s
th at are com plicated by orth opedic h ardw are, u ltrasou n d
m igh t h ave im proved visu alization w h en com pared to CT
an d MRI. In ch ildren , u ltrasou n d can be u sed to iden ti y
join t e u sion s or su bperiosteal f u id associated w ith early
septic arth ritis or osteom yelitis [59]. Ultrasou n d h as proven
to be a u se u l m eth od to gu ide th e radiologist w h en per-
orm in g a diagn ostic or th erapeu tic aspiration , drain age, or
biopsy ( Fig 7-14 ) [60].
4 .6 Nu cle a r m e d icin e
Nu clear im agin g stu dies can detect m u scu loskeletal in ection s
in an early stage, 1014 days be ore ch an ges are visible on
plain x-rays. Stu dies in clu de tech n etiu m -99m labeled
m eth ylen e diph osph on ate (Tc-99m MDP), galliu m -67 citrate,
an d in diu m -111labeled WBCs. Th ese stu dies are particu -
larly u se u l in patien ts w ith m u ltiple sites o in ection an d
in patien ts w ith m etallic h ardw are. Th e sen sitivity is typi-
speci city is low . Th e u se o f u orin e-18 f u orodeoxyglu cose
positron -em ission tom ograph y com pu ted tom ograph y (FDG
PET-CT) is relatively n ovel or th e detection o in ection an d
provides a relatively h igh diagn ostic accu racy an d good
spatial resolu tion .
4 .6 .1 Po sitro n -e m issio n to m o gra p h y co m p u te d
to m o gra p h y
Flu orin e-18 f u orodeoxyglu cose positron -em ission tom og-
raph y-com pu ted tom ograph y is u se u l in speci c cases or
m u scu loskeletal in ection . Th e u se o FDG PET-CT is h elp u l
or localization o th e in ection an d discrim in ation betw een
in ection an d oth er processes th at a ect th e m u scu loskeletal
system . Wh en tryin g to u n derstan d m u lti ocal cases o bon e
in ection FDG PET-CT can be particu larly u se u l [61]. Poten tial
u tu re application s or FDG PET-CT in clu de developm en t
o con trast m edia th at w ill label bio lm or an tim icrobial
peptides to en able su rgeon s to u n derstan d th e u ll exten t
o th e in ectiou s process [62].

a b c
Fig 7-14a c A 2 9 -ye ar-old m an with acute mye loid le uke m ia, pancytope nia, m e thicillin-re sistant Sta phylococcus a ure us bacte re m ia and
absce ss colle ction adjace nt to the right fe mur.
a b X-ray and compute d tomographic scan demonstrate periosteal re action along the me dial aspe ct of the right distal fe moral diaphysis (arrows).
c Ultrasound-guide d aspiration of the absce ss along the right fe m ur was pe rform e d. Image de m onstrate s the ne e dle (arrowhe ads) within
the absce ss colle ction (arrows).

103
 Se ct io n 1Principle s
7Diagnostics
4 .6 .2 Scin tigra p h y
Th e basic bon e scin tigraph y stu dy is th e Tc-99m m eth ylen e
diph osph on ate bon e scan . Th e irst ph ase o im agin g is
obtain ed 60 secon ds a ter tracer in jection (f ow stu dy or
an giogram ) an d con sists o a dyn am ic stu dy o th e region
o in terest. Th e secon d ph ase (blood pool) con sists o static
im ages per orm ed a ew m in u tes a ter in jection . Th e th ird
ph ase is per orm ed 24 h ou rs a ter in jection an d dem on -
strates th e bon e stru ctu res an d sh ow s in creased activity in
th e a ected bon e. Th e th ree-ph ase bon e scan o ers m an y
diagn ostic possibilities in clu din g localization o an in ection ,
discrim in ation betw een cellu litis an d osteom yelitis, an d
delin eation o th e exten t o a bon y in ection [63]. Abn orm al
n din gs or osteom yelitis on Tc-99m bon e scan typically
in clu de in creased f ow activity, blood pool activity, an d
positive u ptake on 3-h ou r im ages ( Fig 7-15 ). Th e th ree-ph ase
bon e scan can becom e positive w ith in 2448 h ou rs a ter
on set o sym ptom s o acu te osteom yelitis [64 ]. Bon e scin tig-
raph y h as a sen sitivity o greater th an 90% , bu t h as a
lim ited speci city, on ly u p to 50% .
A WBC scan don e w ith in diu m -111-tagged leu kocytes an d
m ore recen tly w ith Tc-99m h exam eth yl-propylen eam in e
oxim e (HMPAO)-labeled w h ite cells h as an in creased
a b
Fig 7-15 a d Oste omye litis of the rst toe in a 5 6 -ye ar-old m an.
a X-ray de m onstrate s mild pe rioste al re action at the m e dial aspe ct of the rst distal phalanx. The re is surrounding soft-tissue swe lling.
b d Thre e -phase bone scan with focal hype rpe rfusion on the blood- ow phase ( b ), focal hype re m ia on the blood-pool phase ( c ), and focal
incre ase d bone activity on the de laye d im age s (d ). Findings are com patible with oste omye litis.
104
speci city com pared w ith bon e scan s, particu larly w h en
com plicatin g con dition s, su ch as prior trau m a, prior su rgery,
or diabetes are su perim posed. An overall sen sitivity o 88%
an d speci city o 91% are reported or osteom yelitis [65].
Tech n etiu m -99m su l u r colloid scan n in g can be added to
th e WBC scan protocol to im prove speci city or in ection
in com plicated cases su ch as postarth roplasty in ection s.
In ection is con rm ed w h en th ere is less or n o bon e m arrow
activity on th e su l u r colloid scan in areas w ith in creased
u ptake on th e labeled WBC scan . Activity presen t on bon e
m arrow scan s equ al to or greater th an th at o th e WBC scan
in dicates ph ysiological bon e m arrow activity an d ru les ou t
in ection .
In ection can also be iden ti ed by in jection o galliu m -67
citrate, w h ich leaks rom th e bloodstream in to areas o
in f am m ation . Alth ou gh m ore speci c th an a th ree-ph ase
bon e scan , im age qu ality su ers sligh tly com pared w ith a
th ree-ph ase bon e scan an d im agin g takes lon ger (1872
h ou rs) [66]. Galliu m -67 activity retu rn s to baselin e approx-
im ately 6 w eeks a ter su ccess u l treatm en t o osteom yelitis
an d can th ere ore be u sed to m on itor th e clin ical cou rse o
th e disease [67].
c d
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar

5 Bio p s y
5 .1 In t ro d u ct io n
In traoperative tissu e sam ples provide accu rate specim en s
or detectin g th e in ectin g m icroorgan ism (s), ran gin g rom
65 to 95% [48, 68]. At least th ree to ve in traoperative tissu e
specim en s rom di eren t an atom ical sites sh ou ld be sam pled
or cu ltu re [69 , 70]. Th e low er th e grade o in f am m ation ,
th e m ore sam ples sh ou ld be collected to ran dom ly detect
organ ism s, w h ich are distribu ted in patch es arou n d th e im -
plan t/ prosth esis an d th e bu rden is low . A low er n u m ber o
sam ples m ay create in terpretation di cu lties an d a h igh er
n u m ber leads to an in creased probability o con tam in ation
w ith ou t eviden ce o im proved sen sitivity o th e exam in ation
an d extra cost or th e m icrobiology laboratory. Sw abs h ave
a low sen sitivity an d sh ou ld be avoided [48 ]. Th e speci city
o tissu e Gram stain is very h igh (98% ) bu t its sen sitivity is
low (027% ) [69, 7174], so tissu e Gram stain is n ot rou tin ely
recom m en ded.
In traoperative sam ples sh ou ld be cu ltu red on agar plates
an d in ocu lated in to en rich m en t broth s. Th ey sh ou ld be
in cu bated aerobically in th e presen ce o 5% o CO 2 an d
an aerobically. Som e au th ors recom m en d in ocu latin g syn o-
vial f u id in blood-cu ltu re bottle to im prove th e cu ltu re
sen sitivity [70 ]. Aerobic cu ltu res sh ou ld be in cu bated or u p
to 7 days an d an aerobic cu ltu res (especially broth ) or at
least 2 w eeks [75, 76]. Im portan tly, a system ic seedin g rom
th e an aerobic broth on aerobic an d an aerobic agar plates
sh ou ld be per orm ed a ter 2 weeks to detect m ixed in ection s,
an aerobes, or low -grow in g bacteria [77]. Rare m icroorgan -
ism s su ch as Mycobacteria or Candida species (spp.) m ay be
exam in ed rom th e sam ples con served at -80 C i all cu ltu res
rem ain sterile bu t clin ically an in ection is su spected. Each
di eren t colon y an d m orph otype sh ou ld be iden ti ed an d
su sceptibility tested to avoid m issin g an in ection w ith
di eren t resistan ce pattern s.
Sem iau tom ated tech n iqu es or h om ogen ization ( Fig 7-16 )
h ave been in vestigated to im prove th e diagn ostic yield o
m icroorgan ism s [78, 79].
Con dition s or disru ption , su ch as du ration , speed, liqu id
volu m e, bead size, or am ou n t o beads are im portan t to
avoid m icrobial destru ction . Th e h om ogen ized sam ples can
be cu ltu red on solid an d in liqu id m edia an d also be in ves-
tigated regardin g n eu troph ils (a ter May Gru n ew ald-Giem sa
stain in g) an d bacteria (a ter Gram stain ) despite th e low
sen sitivity o direct exam in ation (less th an 10% ) [24]. Th is
sam ple can be u sed also or 16S rDNA PCR, m u ltiplex poly-
m erase ch ain reaction (PCR) or m icroarray. Som e au th ors
su ggested in trodu cin g th e bead-m ill su spen sion in blood-
cu ltu re bottle. Th u s, au tom ated system detection can be
u sed to redu ce tim e to bacterial detection [44, 80]. Neverth eless,
som e m ixed in ection s can be m issed w ith th e recovery o
on ly th e astest grow in g bacteria.

a b
Fig 7-16 a b Two se miautom ate d de vice s for hom oge nization of intraope rative spe cim e ns
colle cte d in ste rile vials. Afte r the addition of 10 m L ste rile wate r and 10 ste rile stainle ss-ste e l
be ads (4 m m diam e te r), the vials are shake n on a be ad m ill for 2 m inute s and 30 se conds, or
30 Hz pe r minute .

105
 Se ct io n 1Principle s
7Diagnostics
Th e m icroorgan ism s isolated rom sin u s tracts u su ally rep-
resen t m icrobial colon ization o th e w ou n d or su rrou n din g
skin , rath er th an th e path ogen o th e deep-tissu e in ection .
Sin ce th ese resu lts are m isleadin g, cu ltu re o th e sin u s tract
sh ou ld be avoided [81, 82]. On ly isolation o S aureus rom
sin u s tracts is predictive o th e cau sative path ogen o th e
bon e or im plan t-associated in ection [83]. Tw o pairs o blood
cu ltu res sh ou ld alw ays be collected in case o ever or ch ills
to detect bloodstream -born e organ ism s [6, 48].
5 .2 An t ib io t ics in t e r fe re n ce w it h d ia gn o s is
5 .2 .1 Wh e n to sto p a n tib io tics?
Sen sitivity o periprosth etic tissu e cu ltu re is redu ced in
patien ts receivin g an tim icrobial th erapy rom 77% to 48%
to 41% as th e an tim icrobial- ree in terval be ore su rgery
decreases rom greater th an 14 days, to 4 to 14 days, to 0 to
3 days, respectively [7 0]. Th ere ore, an tim icrobial th erapy
sh ou ld be discon tin u ed at least 3 w eeks prior to collectin g
in traoperative cu ltu re specim en s, w h en possible. Th is lon ger
in terval w ill im prove th e likelih ood o diagn osis [6, 79, 84].
Pro p h yla ctic a n tib io ticsw h e n to a d m in iste r th e d o se?
Despite a clear su spicion o im plan t-associated in ection ,
th e in ectin g path ogen is n ot alw ays su ccess u lly isolated
rom th e in traoperative cu ltu res. Som e au th ors postu late
th at proph ylactic an tibiotics cou ld in ter ere with th e isolation
o th e path ogen rom th e in traoperative cu ltu res [43 , 8 1 , 85 ].
As a resu lt, proph ylactic an tibiotics are o ten w ith h eld
u n til in traoperative cu ltu res are obtain ed. Neverth eless, on e
sh ou ld be aw are o th e adverse con sequ en ces o th is practice
th at m ay resu lt in system ic dissem in ation o in ection [8688].
For in traoperative proph ylaxis, a rst- or secon d-gen eration
ceph alosporin is recom m en ded, w h ich sh ou ld be adm in is-
tered 3060 m in u tes be ore in cision . Th e du ration o pro-
ph ylaxis sh ou ld n ot exceed 24 h ou rs. In cen ters w ith a low
in ciden ce o in ection , a sin gle dose is su cien t [86].
5 .2 .2 Tra n sp o rt to th e la b o ra to ry
Tissu e biopsies, syn ovial f u id, bon e, an d oth er m icrobio-
logic specim en s sh ou ld reach th e m icrobiology laboratory
correctly iden ti ed, n u m bered, an d at room tem peratu re,
as qu ickly as possible, ideally w ith in 4 h ou rs in sterile
con tain ers. I th is deadlin e can n ot be m et, tran sport m e-
diu m m u st be u sed to keep ragile bacteria an d an aerobes
alive. It is essen tial th at sam ples are accom pan ied by clin ical
in orm ation su ch as an tibiotic treatm en t, in ectiou s h istory,
an d type o im plan t. An y delay in delivery m u st be m en tion ed
to th e m icrobiology laboratory. Sam ples m u st be h an dled
in a class 2 biosa ety cabin et by a tech n ician w earin g dispos-
able overalls an d gloves an d u sin g sterile equ ipm en t.
106
5 .2 .3 Micro b io lo gica l e xa m in a tio n s
Biopsies, syn ovial f u id, bon e, an d tissu es in con tact w ith
im plan ts are u sed or h istology, m icroscopic exam in ation ,
an d m icrobiological cu ltu re. Microscopic exam in ation m ay
in clu de a Gram stain (ie, speci c bu t n ot sen sitive, see top-
ic 4 o th is ch apter) an d qu an ti cation o leu kocytes an d
sem iqu an titative assessm en t o n eu troph ils. Th e u se o sw abs
or cu ltu re is n ot recom m en ded [1, 36].
Clin ical sam ples are u su ally in ocu lated on gen eral agar plates,
su ch as blood agar an d in cu bated aerobically or/ an d a su p-
plem en ted ch ocolate agar in cu bated in 510% o CO 2 or
at least 7 days); agar or an aerobic bacteria, su ch as blood
agar or Sch aedler agar plates in cu bated an aerobically or
pre erably 1 w eek; an d in to a liqu id m ediu m , su ch as
Sch aedler broth , or th ioglycollate broth , w h ich can be u sed
in di cu lt-to-cu ltu re cases (w h en su spicion o grow th , even
1014 days a ter in cu bation ) on di eren t w ell-selected agar
plates in di eren t atm osph eres.
Th e u se o blood cu ltu re vials (particu larly w ith an tibiotic
absorben t in th e case o an tibiotic treatm en t) in au tom ated
m icrobial system detection cou ld be con sidered. Oth er m edia
cou ld be added depen din g on th e particu lar clin ical con text.
Wh en readin g th e plates it is im portan t to look or th e di -
eren t appearan ces o colon ies, su ch as di eren t m orph otypes
in clu din g sm all-colon y varian ts [89 , 9 0 ].
Som e in vestigators h ave su ggested th at cu ltu re plates m ay
be con tam in ated du rin g th e sam plin g procedu re an d/ or by
prolon gin g th e tim e o in cu bation o plates [9193]. A recen t
stu dy sh ow ed th at by ollow in g som e im portan t basic m i-
crobiological recom m en dation s, su ch as to per orm th e
procedu res in sterile con dition s or to ollow th e in terpretive
criteria o positivity [84, 94], th ey did n ot observe an y in crease
in th e rate o con tam in ation by in cu batin g th e plates or u p
to 2 w eeks [68].
Iden ti cation an d an tibiotic su sceptibility testin g m u st be
per orm ed on all isolated colon ies ( Fig 7-17 ).
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar
Determ in ation o th e m in im u m in h ibitory con cen tration
or th e typically u sed an tibiotics is recom m en ded. Microbi-
ologists m u st be cau tiou s w ith iden ti cation s obtain ed rom
previou sly iden ti ed organ ism s rom oth er laboratories,
particu larly or coagu lase-n egative staph ylococci or w h ich
th e reprodu cibility o iden ti cation is som etim es lim ited. In
case o dou bt, u se o m olecu lar iden ti cation , su ch as16S
rRNA, sodA, tu , rpoB gen e sequ en cin g, or th e di eren t strain s
can be ju sti ed. Th e isolated bacterial strain s sh ou ld be sys-
tem atically preserved by reezin g or clin ical con sideration s.
Molecu lar biology m eth ods can com plem en t con ven tion al
tech n iqu es o cu ltu re with ou t su bstitu tin g or th em . Th ere ore,
periim plan t-tissu e cu ltu res can , h ow ever, be alsely n egative
becau se o previou s an tim icrobial th erapy, low in ocu lu m
o m icroorgan ism , a bio lm state o th e in ection , in adequ ate
tissu e specim en s, in appropriate cu ltu re m ediu m , in adequ ate
cu ltu re in cu bation tim e, or a prolon ged tim e to tran sport
th e specim en to th e laboratory [36].
Cu ltu rin g o m u ltiple sam ples h as been sh ow n to in crease
diagn ostic accu racy an d th ere is grow in g eviden ce to su pport
th e u tility o n ew preparatory tech n iqu es. A Dan ish team
developed an all-in -box con cept sam plin g to avoid m issin g
or u n su itable tran sport m ediu m rom th e operatin g room
[95]. In th e u tu re, th is con cept cou ld be u sed to provide an d
im plem en t stan dardized sam plin g procedu res based on
in tern ation al gu idelin es [95].
Fig 7-17 Diffe re nt m orphotype s of S a ure us in hip infe ction with
the sam e antibiotic susce ptibility patte rn ( pe rsonal data, Nante s
Unive rsity hospital).
5 .2 .4 Po lym e ra se ch a in re a ctio n te s t
Molecu lar m eth ods h ave been developed to im prove th e
diagn osis o in ection , despite its u se bein g con troversial
[96]. Alth ou gh m olecu lar m eth ods h ave proved to be h elp-
u l, strict con dition s w ith speci cally train ed person n el to
avoid an y con tam in ation are n eeded [9799].
Polym erase ch ain reaction is a relatively sim ple tech n iqu e
th at can detect a n u cleic acid ragm en t an d am pli y th is
sequ en ce. In recen t years, m odi cation s h ave been developed
rom th e basic PCR m eth od to im prove per orm an ce an d
speci city, an d to ach ieve th e am pli cation o oth er m ol-
ecu les o in terest in research , su ch as ribon u cleic acid (RNA)
[100]. Som e o th ese varian ts are:
Mu ltiplex PCR: sim u ltan eou sly detects several deoxyri-
bon u cleic acid (DNA) sequ en ces by addin g th e sets o
prim ers o in terest.
Nested PCR: in creases th e speci city by addin g a
secon d PCR w ith n ew prim ers th at h ybridize w ith in
th e am pli ed ragm en t in th e rst PCR.
Sem iqu an titative PCR: allow s an approxim ation to th e
relative am ou n t o n u cleic acids presen t in a sam ple.
Reverse tran scriptase-polym erase ch ain (RT-PCR):
gen erates am pli cation o RNA by syn th esis o cDNA
(DNA com plem en tary to RNA) th at is th en am pli ed
by PCR.
Real-tim e PCR: per orm s qu an ti cation o n u cleic acid
copies obtain ed by PCR.
Polym erase ch ain reaction tech n iqu es can detect a speci c
bacteria (or a grou p o bacteria by m u ltiplex PCR), or a ran ge
o bacteria, by targetin g th e 16S rRNA gen e w ith sequ en cin g
o th e am pli ed produ ct as th is target is u n iversally presen t
in bacteria (broad-ran ge PCR) [1 0 1 ]. Th ere ore, alth ou gh
less sen sitive com pared w ith m u ltiplex gen u s-orien ted PCR
[47], broad-ran ge PCR allow s th e iden ti cation o bacteria
previou sly n ot th ou gh t to cau se in ection w h ereas speci c
PCR (in clu din g m u ltiplex PCR) are lim ited to th ose organ ism s
or w h ich targeted prim ers are in clu ded.
Th e m ain disadvan tages o broad-ran ge PCR are lack o
sen sitivity, alse-positive resu lts stem m in g rom con tam in a-
tion , n eed o su bsequ en t sequ en cin g, an d ch allen ge o resu lt
in terpretation [96, 102]. Also, th is approach does n ot in dicate
w h eth er a polym icrobial or solitary m icrobial in ection is
presen t; in th e orm er circu m stan ce, sequ en ce an alysis m ay
be u n in orm ative (ie, du e to overlappin g electroph oregram
peaks) or m isleadin g (ie, du e to m issed detection o m in ority
107
 Se ct io n 1Principle s
7Diagnostics
species). Neverth eless, a su bclon in g step is th e on ly w ay to
reveal th e m ixed bacteria im plicated in th e PJI, bu t it is n ot
available in all m icrobiology laboratories an d it is n ot ap-
plicable in daily practice rou tin e [103].
Th e valu e o PCR w as m ain ly in vestigated in syn ovial f u id
or periprosth etic tissu e specim en s [79 , 10 4, 1 05 ], w h ereas
son ication f u id w as evalu ated m ore recen tly [102, 106, 107].
Several com m ercial m u ltiplex PCR kits are available to
detect th e m ost com m on ly in volved bacteria, especially in
bloodstream in ection s. Th e com bin ation o tw o com ple-
m en tary diagn ostic m eth ods, son ication o rem oved im plan ts,
an d m u ltiplex real-tim e PCR o th e resu ltin g son ication
f u id can im prove th e diagn ostic accu racy o PJI an d peri-
im plan t in ection , particu larly am on g patien ts th at h ad
received an tibiotic treatm en t prior to su rgery an d in poly-
m icrobial in ection s [102, 107]. In a recen t stu dy, th e path ogen
detection w as im proved by m u ltiplex PCR com pared to
cu ltu re-based tech n iqu es. Th e detection rate o polym icro-
bial in ection s w as 29% by m u ltiplex PCR versu s 1317%
by cu ltu re. Moreover, abou t on e-th ird o PJI cases w ere
n egative by cu ltu re, w h ereas m u ltiplex PCR m issed on ly
on e case o PJI. Th is PJI w as cau sed by P acnes, or w h ich
speci c prim ers w ere n ot in clu ded in th e m u ltiplex prim er
set an d can th ere ore n ot be detected by th is PCR kit [107].
Th ese resu lts w ere in agreem en t w ith an oth er stu dy, w h ich
dem on strated th at sen sitivity o son ication f u id cu ltu res
w as redu ced to 42% in patien ts th at h ad received an tim i-
crobial treatm en t, w h ereas m u ltiplex PCR o son ication
f u id rem ain ed at 100% [102, 108].
Fu rth er stu dies are probably n eeded to optim ize th e process-
in g procedu re w ith m odi ied speci ic prim ers in clu din g
low -viru len ce bacteria in volved in ch ron ic or delayed PJI
like P acnes, Corynebacterium spp. or an aerobes, bu t also h e-
m atogen ou sly acqu ired bacteria su ch as Salmonella spp. or
Campylobacter spp. In act, a recen t stu dy proposed a pan el
o 10 real-tim e PCR assays speci cally targetin g th e bacteria
th at m ost requ en tly cau se PJI [47]. Th e au th ors con clu ded
th at PCR o son ication f u ids is m ore sen sitive th an tissu e
cu ltu re or th e m icrobiological diagn osis o PJI an d provides
sam e-day PJI diagn osis.
5 .2 .5 IBIS T5 0 0 0 o r e le ctro sp ra y io n iza tio n m a ss
sp e ctro m e try te ch n o lo g y
Th is latest tech n iqu e is based on n u cleic-acid am pli cation
w ith h igh -per orm an ce electrospray ion ization m ass spec-
trom etry (ESI-MS) an d base-com position an alysis. Th is
tech n ology com bin es tw o w ell-kn ow n m eth ods: PCR an d
108
m atrix-assisted laser desorption / ion ization (MALDI-TOF).
Th e latter w as in trodu ced eigh t years ago in m icrobiology
laboratories to iden ti y qu ickly th e bacteria an d u n gi. Ma-
trix-assisted laser desorption / ion ization can be u sed as a ast
trackin g iden ti cation m eth od rom syn ovial f u id or bead-
m ill sam ples directly in trodu ced in to blood-cu ltu re bottles
to redu ce th e tim e to detection an d iden ti cation [10 9 ]. Th is
in n ovative bu t costly system en ables th e iden ti cation an d
qu an ti cation o a broad set o path ogen s, in clu din g all
kn ow n bacteria, all m ajor grou ps o path ogen ic u n gi (3400
bacteria, 40 Candida spp.) an d th e m ajor am ilies o viru ses
th at cau se disease in h u m an s an d an im als, togeth er w ith
th e detection o viru len ce actors an d an tibiotic resistan ce
m arkers [110, 111]. Th e IBIS T5000 can also detect bacterial
gen es th at con trol an tibiotic resistan ce, so th at both species
iden tity an d an tibiotic su sceptibility can be reported in a
ew h ou rs. How ever, a recen t stu dy sh ow ed th at m an y o
th e revision arth roplasty cases h ad positive resu lts by th is
tech n iqu e, sh ow in g a very low speci city an d m akin g th e
resu lt in terpretation very di cu lt [11 2 ].
Th e IBIS T5000 Biosen sor Plex-ID PCR-electrospray ion ization
m ass spectrom etry (PCR-ESI/ MS) system , alth ou gh n o lon -
ger m arketed or rou tin e u se, w ith som e developm en ts, m ay
be a prom isin g tool. How ever, th e tech n ology w as recen tly
evalu ated w ith son ication f u id an d syn ovial f u id or th e
detection o PJI [1, 112]. Th ey ou n d th at th e sen sitivity or
th e Plex-ID system to be arou n d 80% ; th e speci city, an d
th ere ore th e in terpretation , rem ain s di cu lt. Th e latest
stu dies w ere per orm ed com parin g PCR-ESI/ MS to cu ltu re
w ith son ication f u ids. Th e sen sitivities or detectin g PJI
w ere 77.6% or PCR-ESI/ MS an d 69.7% or cu ltu re
(P = .0105). Th e speci cities w ere 93.5 an d 99.3% , respec-
tively (P = .0002). PCR-ESI/ MS w as m ore sen sitive bu t less
speci c th an cu ltu re or PJI diagn osis w h en per orm ed on
m aterial dislodged rom th e su r aces o explan ted orth ope-
dic prosth eses. Th is m eth od m ay be a u se u l tool or th e
rapid detection o im plan t-associated in ection an d/ or as an
adju n ctive m eth od or select cases o arth roplasty ailu re,
especially in case o slow -grow in g bacteria, low in ocu lu m
or an tibiotic treatm en t prior to su rgery [11 3]. Applied to
syn ovial f u id, PCR-ESI/ MS o syn ovial f u id h as a sim ilar
sen sitivity to cu ltu re albeit a low er speci city. PCR-ESI/ MS
can be per orm ed in approxim ately 1216 h ou rs an d provides
n ot ju st accu rate m icrobial iden ti cation , even in m ixed
in ection , bu t also in orm ation on selected an tim icrobial
resistan ce m arkers. Neverth eless, du e to som e lim itation s
o th ose stu dies, u rth er prospective stu dies with resh sam ples
(n ot rozen ) w ill n eed to be per orm ed [114].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar
5 .2 .6 Histo lo gy
Sta n d a rd
Histopath ological exam in ation dem on stratin g acu te in f am -
m ation , eviden ced by a n eu troph ilic in iltrate in areas
con tigu ou s to th e im plan t th at appear to be in ected, h as a
sen sitivity o > 80% an d a speci city o > 90% or diagn osin g
PJI [115]. Th is exam in ation can be per orm ed on xed tissu e
(stan dard), or in resh - rozen section s or im m ediate in tra-
operative con irm ation o acu te in lam m ation , gu idin g
in traoperative decision m akin g [116].
Th e classic de n ition o acu te in f am m ation in th e peripros-
th etic tissu e varies betw een th e au th ors rom 1 to 10 or
m ore n eu troph ils per h igh -pow er eld at a m agn i cation
o 400x [11 7 ]. A ew years ago, Moraw ietz an d colleagu es
in trodu ced clearly de n ed h istopath ological criteria or a
stan dardized evalu ation o th e periprosth etic m em bran e,
w h ich can appear in cases o total join t arth roplasty revision
su rgery [11 8 ]. Th u s, based on h istom orph ological criteria,
ou r types o periprosth etic m em bran es w ere de n ed:
Wear-particle in du ced type (detection o oreign body
particles; m acroph ages an d m u ltin u cleated gian t cells
occu py at least 20% o th e area: type I)
In ectiou s type (gran u lation tissu e w ith n eu troph ils,
plasm a cells, an d ew , i an y, w ear particles: type II)
Com bin ed type (aspects o type I an d type II occu r
sim u ltan eou sly: type III)
In determ in ate type (n eith er criteria or type I n or type
II are u l lled: type IV) [119]
Alth ou gh o ten orgotten , th e h istological an alysis rem ain s
an im portan t m eth od to ru le ou t in ection sin ce th e n egative
predictive valu e ran ges betw een 90% an d 100% in m ost
stu dies. Th is n din g m akes it a very im portan t in vestigation
com plem en tary to m ost oth er m arkers th at are m ain ly h elp-
u l to con sider th e possibility o PJI. I th ere is n o clin ical
su spicion o in ection an d th ere are less th an ve n eu troph ils
per h igh -pow er eld, th ere is 91% ch an ce o absen ce o
in ection [120].
Th e advan tage o h istology is th at it is u n likely to be m odi ed
by th e previou s u se o an tibiotics. On th e oth er h an d, th e
disadvan tage o th is tech n iqu e is th e in ability to iden ti y th e
cau sative path ogen . Th e an tim icrobial th erapy can n ot be
directed by th is m eth od. Th e degree o in iltration w ith
in f am m atory cells varies am on g specim en s even w ith in
in dividu al tissu e section s, th e in terobserver variability, th e
in terpretation w h en a patien t su ers an in f am m atory join t
disorder m ay be tricky, an d alse n egative cases cau sed by
low -viru len t path ogen s, su ch as P acnes, Actinomyces spp., or
coagu lase-n egative staph ylococci [121]. Th e resu lts are avail-
able w ith in several days so th e h istological exam in ation o
resh - rozen tissu es m ay be a ast altern ative to su pport th e
diagn osis o in ection .
Fre sh -fro ze n se ctio n s
Fresh - rozen section an alysis is a qu ick altern ative tool to
su pport th e diagn osis o in ection becau se th e resu lts are
available w h ile th e su rgeon is still in th e operatin g room .
Wh en th e poten tial or in ection rem ain s a ter a th orou gh
preoperative evalu ation , a positive resu lt o th is tech n iqu e
su pports th e diagn osis o in ection , w h ereas th e absen ce o
acu te in f am m ation doesn t com pletely exclu de a diagn osis
o in ection . In a recen t stu dy, u sin g cu rren t h istopath ology
gradin g system s, rozen section s w ere speci c bu t sh ow ed
low sen sitivity w ith respect to th e P acnes in ection . A n ew
th resh old valu e o a total o ten or m ore polym orph on u clear
leu kocytes in ve h igh -pow er elds m ay in crease th e sen -
sitivity o rozen section , with m in im al im pact on speci city
[122].
In an oth er stu dy, in traoperative h istology h ad also a h igh
speci city an d n egative predictive valu e, bu t a low sen sitivity
an d positive predictive valu e or predictin g in ection in th e
settin g o revision elbow arth roplasty. Th ere ore, in traop-
erative h istology sh ou ld be u sed in con ju n ction w ith oth er
stu dies to de n itively establish th e diagn osis o in ection in
th e settin g o revision elbow arth roplasty [123].
Con sequ en tly, th is tech n iqu e sh ou ld be con sidered as a valu -
able part o th e diagn ostic w orku p or patien ts u n dergoin g
revision arth roplasty [124].
109
 Se ct io n 1Principle s
7Diagnostics

5 .2 .7 Ou tlo o k o n m icro b io lo gica l e xa m in a tio n s
Th e ailu re to isolate th e cau sative bacteriu m in cases o
im plan t in ection o ten leads to th e diagn ostic con clu sion
o aseptic ailu re, even in cases in w h ich clin ical sign s o
in ection clearly exist, th u s leadin g to grave con sequ en ces
or th e patien tth e th erapy or in ection is n ot pu rsu ed. In
recen t years, a variety o n ew tech n ologies h ave been pro-
posed th at allow a m ore accu rate m icrobiological diagn osis
[125].
Ca lo rim e try
Microcalorim etry m easu rin g h eat rom replicatin g m icro-
organ ism s in cu ltu re w as rst evalu ated as a rapid, accu rate,
an d sim ple screen in g m eth od or platelet con cen trates.
Th erea ter, th e poten tial o m icrocalorim etry or detection
o bacterial grow th in cerebrospin al f u id (CSF) in a rat
m odel o bacterial m en in gitis was also tested allowin g rapid
an d accu rate diagn osis o bacterial m en in gitis rom a sm all
volu m e o CSF w ith low detectable bacterial den sity [126].
In terestin gly, th e sh ape o th e pow er-tim e cu rve w as species-
speci c an d in depen den t rom th e in itial con cen tration o
m icroorgan ism s. Th e h eat f ow (W) in dicates an in crease
o th e h eat produ ction du e to th e bacterial m etabolism
du rin g replication [127]. Th is tech n iqu e w as recen tly evalu -
ated in a prospective stu dy o 90 patien ts with acu te arth ritis,
in w h om arth rocen tesis w as per orm ed (u n pu blish ed data).
A com parison betw een syn ovial f u id cu ltu res an d m icro-
calorim etric detection w as per orm ed (detection lim it 0.25
W, positive de n ed as h eat-f ow > 10 W). In patien ts
w ith septic arth ritis, th e cau sative organ ism w as detected
by m icrocalorim etry in all cases a ter a m ean o 4.3 h ou rs
(ran ge, 2.87.5 h ou rs) in stead o 2448 h ou rs w ith con ven -
tion al cu ltu res. Microcalorim etry o syn ovial f u id allow ed
accu rate discrim in ation betw een septic an d n on septic ar-
th ritis w ith in 8 h ou rs. In a recen t stu dy, th e sen sitivity an d
speci city o m icrocalorim etry o son ication f u id w ere 100%
an d 97% , respectively. Th e m ean tim e to detection , de n ed
as tim e to reach a risin g h eat f ow sign al o 20 W, w as 10.9
h ou rs, m easu red a ter equ ilibration n eeded to get accu rate
m easu rem en t. Microcalorim etry o son ication f u id seem s
to be a reliable an d a ast m eth od to detect th e presen ce o
m icroorgan ism s in orth opedic im plan t-related in ection
( Fig 7-18 ) [1 2 8 ]. In th e u tu re, a com bin ation o m eth ods
w ou ld allow better an d qu icker diagn osis o in ection w h en
rapid diagn osis o in ection is im portan t [129].
Early diagn osis o septic arth ritis or im plan t-related in ection s
m igh t prom pt earlier treatm en t an d im prove patien t ou t-
com e, redu cin g h ospital stay an d savin g m on ey. In addition
to syn ovial f u id, oth er patien t sam ples can be in vestigated,
su ch as son ication f u id or bead-m ill su spen sion .

400.00
)
W

(
w
o
l
f
t
200.00
a
e
H
0.00
0.00 10.00 20.00 30.00 40.00 50.00
Tim e (h )

Fig 7-18 Se ve n diffe re nt curve m e asure m e nts with he at- ow

calorim e try from sonication liquid afte r im plant e xplantation.

110 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar
An tib o d ie s
Du e to th e com plexity o th e path ogen esis o im plan t-asso-
ciated in ection , th e in terest in serological tests in th is eld
w as low . For detectin g an tibodies, appropriate an tigen s n eed
to be de n ed [130, 131]. Serological tests cou ld be particu larly
u se u l in cases o alse-n egative cu ltu res, relapse o in ection
or or th e ollow -u p evalu ation du rin g an d a ter an tim icro-
bial treatm en t. In 2011, a n ew staph ylococcal IgM en zym e-
lin ked im m u n osorben t assay (ELISA) w as adapted or th e
diagn osis o delayed PJI, com m on ly diagn osed at advan ced
stages o disease. Th is test, previou sly described to detect
seru m an tibodies to staph ylococcal bio lm polysacch aride
an tigen s in late on set in ection s o syn th etic vascu lar gra ts,
w as applied to bon e an d join t in ection s. Th e research ers
ou n d a statistical di eren ce betw een th e grou p w ith delayed
PJI (> 1 year a ter im plan tation ) an d th e grou p w ith join t
prosth eses w ith ou t in ection an d th e con trol grou p, ie,
su bjects w ith ou t prosth esis an d in ection . Th e test sh ow ed
a sen sitivity o 90% an d speci city o 95% , w h en a cu t-o
o 0.35 ELISA u n it w ere applied. Th e IgG grou p w as n ot
evalu ated becau se th e respon se is m ain tain ed as lon g as th e
an tigen ic stim u lu s is presen t. Th is test cou ld be u sed to
evalu ate th e respon se o in ection to treatm en t [13 2 ]. Oth er
can didate an tigen s sh ou ld be screen ed to im prove th e
sen sitivity an d speci city o th is test, perh aps in com bin ation
w ith oth er tests. More recen tly, a stu dy sh ow ed th at th ere
w ere sign i can tly h igh er levels o an tiextracellu lar protein
IgG in sera o in ected an im als th an in con trols by u sin g an
en zym e-lin ked im m u n osorben t assay. Sign i can tly h igh er
an tiextracellu lar protein IgG levels in in ected patien ts com -
pared to th e con trols were ou n d; h owever, receiver operatin g
ch aracteristic cu rves did n ot aid in diagn osin g in ection .
Fu rth er stu dies are n eeded to separate th ese protein s an d
in vestigate th eir an tigen icity or th e diagn osis o peripros-
th etic in ection in h u m an s [13 3 ].
a b
Fig 7-19 a b Ele ctron m icroscopy of a Sta phylococcus e pide rm idis bio lm on a polye thyle ne surface .
Recen tly, In Gen BioScien ces developed a n ew serological
test called BJI In oplex adapted w ith th e Lu m in ex tech n ol-
ogy. Lu m in ex tech n ology is backed u p by colored polystyren e
m icrosph eres on w h ich th e an tigen s are xed. Th is system
u ses a set o several recom bin an t an tigen s to detect IgG
an ti-S aureus an d Staphylococcus epidermidis. Th e BJI In oPlex
test is a n on in vasive an d ast (2 h ou rs) serology test. Th is
m eth od sh ou ld be tested in th e n ear u tu re to evalu ate its
ability to accu rately aid in th e diagn osis o th e in ection ,
an d in th e biological m on itorin g o an tibiotic treatm en t.
5 .2 .8 So n ica tio n
Microorgan ism s on th e im plan t su r ace orm bio lm s, w h ich
m akes th em di cu lt to detect by con ven tion al m eth ods
su ch as periprosth etic tissu e cu ltu res. Son ication o explan ted
prosth esis is design ed to dislodge m icroorgan ism s rom th e
bio lm s on th e su r ace o explan ted devices. Th e m icroor-
gan ism s in bio lm exist in a low m etabolic or station ary
grow th state. Free-livin g bacteria (ie, plan kton ic bacteria)
are killed by an tibiotics an d th e h ost de en se system , w h ere-
as adh eren t bacteria (ie, bio lm bacteria) can su rvive an d
persist in th e extracellu lar m atrix o th e bio ilm [1 1 5 ]
( Fig 7-19 ).
Son ication w orks by th e in trodu ction o low -in ten sity u l-
trasou n d, so as n ot to cau se bacterial cell destru ction , w h ich
produ ces m icrobu bble orm ation (cavitation ). Microbu bbles
attach to th e su r ace o th e prosth esis an d im plode, releasin g
en ergy. Th en , bacteria disaggregate in to th e liqu id su rrou n d-
in g th e prosth esis, en ablin g cu ltu re o viable m icroorgan ism s
rom th is son ication f u id.
111
 Se ct io n 1Principle s
7Diagnostics

Im plan ts sh ou ld be aseptically rem oved in th e operatin g
room , placed in airtigh t solid con tain ers an d tran sported to
th e m icrobiology laboratory. Son ication in plastic bags sh ou ld
be avoided becau se o risk o con tam in ation du e to pu n ctu re
o bags [84]. Several stu dies h ave dem on strated th e h igh er
sen sitivity an d speci city o son ication f u id cu ltu re th an
periprosth etic tissu e cu ltu re [6 8 , 7 0 , 9 4 , 1 0 2 , 1 3 4 , 1 3 5 ]. In
addition to th e im provem en t o sen sitivity an d speci city,
oth er advan tages o son ication are:
Th e rem oved im plan t sh ou ld be tran sported to th e m icro-
biology laboratory in a sterile con tain er. A ter addition o
Rin gers solu tion or n orm al salin e coverin g abou t 80% o
th e im plan t, th e con tain er sh ou ld be vortexed or 30 secon ds
an d son icated (40 kHz) or 1 m in u te, an d n ally a last vor-
tex step o 30 secon ds be ore platin g th e son ication f u id
( Fig 7-20 ). Som e au th ors add a con cen tration cen tri u gation
step a ter son ication procedu re to con cen trate th e bacterial
load [136].

Im proved diagn osis in patien ts th at received prior
an tim icrobial th erapy
A qu an titative resu lt, w h ich is h elp u l to distin gu ish
betw een con tam in ation an d in ection
High er detection o m ixed in ection s, ie, polym icrobial
in ection s
Di icu lt-to-treat m icroorgan ism s an d di eren t
m orph otypes
Faster resu lts th an periprosth etic tissu e cu ltu res [68]
Prolon ged in cu bation , or as lon g as 2 w eeks, is still recom -
m en ded or periprosth etic tissu e cu ltu res to detect slow -
grow in g path ogen s, su ch as P acnes [7 5 , 7 6 , 1 3 7 ]. A recen t
stu dy sh ow ed th at a prolon ged in cu bation (2 w eeks) is also
recom m en ded or son ication f u id cu ltu res, especially to
detect an aerobes [68].

Cove r 8 0 % with
norm al saline

a b c
Colle ct the prosthe sis Vorte x 3 0 se conds. Plate sonication
in solid airtight 1 m inute .
containe r.

e d
Plate sonication uid. Vorte x 3 0 se conds.

Fig 7-20 a e Sonication proce dure .

112 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

St phane Corve c, Mara Euge nia Portillo, Jose phina A Vossen, Andrej Tram puz, Pe te r J Haar
Th e optim al cu t-o valu e to determ in e a positive son ication
f u id cu ltu re depen ds on w h eth er or n ot a cen tri u gation
con cen tration step is added a ter son ication . Wh en u sin g a
con cen tration step, th e m ost requ en tly u sed cu t-o valu e
w as 200 CFU/ m L [47, 135, 138], w h ile w h en n ot u sin g it, th e
reported cu t-o valu es ran ged rom 1 to 50 CFU/ m L [70, 94,
139]. Despite th is ran ge o cu t-o valu es, cu ltu re o son ica-
tion f u id u su ally yields an u n cou n table n u m ber o CFU/
plate. Usu ally, ew colon ies per plate grow in son ication
f u id cu ltu re w h en patien ts h ad received an tibiotics prior
to su rgery ( Fig 7-21 ), or w h en on ly im plan t lin ers h ave been
su bjected to son ication correspon din g w ith acu te PJI, so
h igh su spicion o previou s an tibiotics u sage. It h as been
reported th at an y grow th sh ou ld be con sidered sign i can t
in patien ts receivin g an tibiotics [94].
Th e role o son ication o lin ers an d polym eth ylm eth acrylate
spacers is u n certain . Regardin g th e in lays, a recen t stu dy
reported th at 17% o PJI cases h ad a m icrobiological grow th
in son ication f u id cu ltu res < 50 CFU/ m L. In all th ese cases,
debridem en t w ith im plan t reten tion w as per orm ed, so on ly
lin ers w ere exch an ged an d su bjected to son ication procedu re
[6 8 ]. Th is observation w as also n oted in a previou s stu dy
[94]. Possible reason s in clu de th e sm aller su r ace area im plan t
com pared to th e total prosth esis [9 4], previou s an tibiotic
u sage, or th e presen ce o n ew er bio lm seen in acu te in ec-
tion s [46, 94, 140].
In terpretation o son ication f u id cu ltu re o polym eth yl-
m eth acrylate spacers du rin g a tw o-stage exch an ge m ay be
ch allen gin g becau se th e spacers are requ en tly an tibiotic-
loaded, m akin g it di cu lt to distin gu ish betw een persisten t
in ection or rein ection du rin g th e secon d-stage exch an ge
an d lack o cu t-o valu es or in vestigation s [14 1 , 1 42 ].
In terestin gly, th e sen sitivity o son ication f u id cu ltu re w as
h igh er in patien ts w ith ch ron ic PJI th an w ith acu te PJI [94].
Th ese n din gs su ggest th at bio lm s in acu te PJI in volve
im m atu re bio lm layers an d th e bacteria are on ly loosely
attach ed to th e su r ace, ie, im m atu re bio lm . In con trast,
bio lm in ch ron ic PJI u su ally con sists o several layers o
rm ly attach ed bacteria requ irin g a m ore e cien t rem oval
procedu re, su ch as son ication . A recen t article dem on strates
th e in vivo n atu ral h istory o im plan t-associated bio lm
orm ation [140].
Vortexin g is a tradition al tech n iqu e or m ixin g w idely u sed
in rou tin e m icrobiology laboratories. It w as also in trodu ced
as a preparatory step be ore son ication to gen erate m icro-
bu bbles, w h ich in crease th e cavitation e ect [70]. Vortexin g
alon e is an easy an d sim ple procedu re, w h ich h as dem on -
strated an acceptable sen sitivity an d speci city, especially
in acu te PJI, an d m ay be u sed or th e diagn osis o PJI in
laboratories w h ere son ication is n ot available [94]. In addi-
tion , vortexin g f u id represen ts a sin gle clin ical sam ple,
reach in g com parable sen sitivity to m u ltiple periprosth etic
tissu e cu ltu res (~70% ). Fu rth erm ore, son ication m ay kill
bacteria, especially Gram -n egative bacilli an d an aerobes,
w h ereas vortexin g h as n ot been sh ow n to be h arm u l to
bacteria.
Tissue s
Sonication
Fig 7-21 Antim icrobial e ffe ct on culture s. Sonication uid culture
re m ains ne gative and only two of four pe riprosthe tic tissue culture s
have microbiological growth.
113
 Se ct io n 1Principle s
7Diagnostics
Despite th e u se o son ication , cu ltu re-n egative cases o PJI
still rem ain . Possible reason s in clu de case m isclassi cation
an d m icroorgan ism s th at do n ot grow u n der th e con dition s
stu died (eg, du e to in appropriate m edia, in adequ ate in cu ba-
tion tim e, loss o viability du rin g specim en tran sport) or
earlier an tim icrobial th erapy [14 3 1 4 6 ]. A research grou p
evalu ated th e BacT/ Alert FAN aerobic an d an aerobic blood-
cu ltu re bottles in ocu lated w ith son ication lu id or th e
diagn osis o im plan t-associated in ection an d com pared it
w ith periprosth etic tissu e cu ltu re an d son ication f u id cu l-
tu re. Th ey detected all im plan t-associated in ection cases
in clu din g th ose in w h om patien ts h ad previou sly received
an tibiotics with a speci city o 100% . Moreover, th e detection
o path ogen s by th is system sign i can tly redu ced th e tim e
to a positive resu lt com pared w ith th e oth er tech n iqu es.
Th is m ay be a prom isin g an d easy-to-per orm m eth od th at
m ay im prove th e diagn osis o PJI.
Fin ally, son ication f u id con tain s a h igh qu an tity o bacteria,
m akin g th is sam ple su itable or u rth er advan ced m icrobial
an d im m u n ological an alyses (eg, PCR, MALDI-TOF, m icro-
calorim etry, biom arker determ in ation , gen e expression ).
114
6 Co n clu s io n
Som e im plan ts m ay be colon ized by bio lm -dwellin g bacteria,
w ith th e bacteria n ot bein g clin ically apparen t [147, 148]. Th e
proportion o su ch asym ptom atically colon ized devices is
u n kn ow n an d largely depen ds on th e diagn ostic m eth od
em ployed. Th e resu lts o h igh ly sen sitive diagn ostic tech n iqu es
su ch as son ication , PCR, or n ew er m olecu lar tech n iqu es are
di cu lt to in terpret an d u rth er lon g-term stu dies are n eeded
to distin gu ish con tam in ation du rin g sam ple processin g rom
real-device colon ization . It is also u n clear w h eth er all
asym ptom atic colon ization becom es, at som e poin t, clin ically
apparen t as in ection . Som e colon ized im plan ts m ay rem ain
asym ptom atic lon g-term , w h ere th e h ost keeps th e bio lm
m icroorgan ism s perm an en tly su ppressed. It is also u n clear
wh at triggers asym ptom atic bio lm bacteria to start detach in g,
replicatin g, an d cau sin g a clin ical in ection .
On th e on e h an d, research an d developm en t o n ew m eth ods
are requ ired to im prove th e diagn ostic yield an d accu racy,
sh orten th e detection tim e, an d to u lly au tom ate th e com plete
procedu re. On th e oth er h an d, critical clin ical observation
rom m u ltidisciplin ary team s w ith speci c kn ow ledge o
bio lm in ection s is also u n dam en tal. As an exam ple, ju st
by observin g w h eth er a prosth esis ailu re occu rs early (w ith -
in th e rst 2 years a ter im plan tation ), th e probability th at
in ection is th e reason or th e ailu re is arou n d 70% com pared
w ith 16% probability o it bein g an aseptic loosen in g [13].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
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Microbiol. 2014 Ju n ;52(6):2248 2250.
145. Klo e s e l B, Be live a u M, Pa t e l R, e t a l.
Bu lleid ia extru cta periprosth etic h ip
join t in ection , Un ited States. Emerg
In ect Dis. 2013 Ju l;19(7):1170 1171.
146. Ta n d e AJ, Cu n n in gh a m SA, Ra o u lt D,
e t a l. A case o Q ever prosth etic join t
in ection an d description o an assay
or detection o Coxiella bu rn etii.
J Clin Microbiol. 2013 Jan ;51(1):66 69.
147. Ro h a ce k M, We is s e r M, Ko b za R, e t a l.
Bacterial colon ization an d in ection o
electroph ysiological cardiac devices
detected w ith son ication an d swab
cu ltu re. Circulation. 2010 Apr
20;121(15):16911697.
14 8. Rie ge r UM, Pie re r G, Lu s ch e r NJ, e t a l.
Son ication o rem oved breast im plan ts
or im proved detection o su bclin ical
in ection . Aesthetic Plast Surg. 2009
May;33(3):404 408.
119
 Se ct io n 1Principle s
7Diagnostics

120 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

 Se ctio n

Special
situations 2
Se ct io n 2
Spe cial situations
8 Op e n fra ct u re s
Ch aralam p o s G Zalavras 123

9 .1 In fe ct io n a ft e r fra ct u re
Martin A McNally 139

9 .2 In fe ct e d n o n u n io n
Joh an Lam m e ns, Pe te r E Och sne r, Martin A McNally 167

10 In fe ct io n a ft e r jo in t a rt h ro p la s t y
Anton ia F Ch e n, Carlo L Rom an , Lo re n zo Drago,
Javad Parvizi 189

11.1 Se p t ic a rt h rit is
Ann a Co ne n , Olivie r Bo re ns 213

11.2 Se p t ic a rt h rit is a ft e r a n t e rio r cru cia t e

liga m e n t s u rge r y
Parag San ch e ti, AJ Ele ctricwala, Ash o k Sh yam ,
Kailash Patil 227

12 Sp o n d ylo d is cit is
Pau l W Millh o u se , Cale b Be h re n d , Ale xan d e r R Vaccaro 235

13 So ft-t is s u e in fe ct io n s
Sve n Hu n ge re r, Mario Mo rge n ste rn 245

14 Op e n w o u n d s
Jorge Danie l Barla, Lu cian o Ro ssi, Yo av Rose n th al,
Ste ve n Ve lke s 265
Charalampos G Zalavras
8 Op e n fra ctu re s
Ch aralam p o s G Zalavras
1 Ba s ics
Th e de n in g ch aracteristic o an open ractu re is associated
so t-tissu e trau m a th at creates com m u n ication o th e ractu re
site with th e ou tside en viron m en t [1]. High -en ergy open rac-
tu res are m ore com m on in you n ger m en an d low -en ergy
open ractu res in older wom en [2]. Open diaph yseal ractu res
o th e tibia, em u r, an d h u m eru s are u su ally th e resu lt o
h igh -en ergy trau m a w ith road tra c in ju ries bein g th e m ost
com m on m ech an ism [2]. Open diaph yseal ractu res o th e
tibia, em u r, an d h u m eru s h ave resu lted rom road tra c
in ju ries in 46% , 54% , an d 50% o cases, respectively [2].
Open ractu res carry an in creased risk or com plication s,
su ch as in ection an d n on u n ion , an d requ ire a prin ciple-
based approach to decrease th e m orbidity an d im prove th e
progn osis. Th e prin ciples o open ractu re m an agem en t
con sist o care u l assessm en t o th e patien t an d th e in ju ry,
early system ic an tibiotic th erapy th at can be su pplem en ted
by local an tibiotic delivery, th orou gh debridem en t, w ou n d
m an agem en t w ith so t-tissu e coverage, an d stabilization o
th e ractu re. Man agem en t o open ractu res based on th ese
prin ciples will h elp preven t in ection , ach ieve ractu re h ealin g,
an d restore u n ction in th ese ch allen gin g in ju ries.
2 As s e s s m e n t a n d cla s s ifica t io n
2 .1 Pa t ie n t a n d in ju r y a s s e s s m e n t
Open ractu res m ay be associated w ith seriou s an d poten -
tially li e-th reaten in g abdom in al, th oracic, h ead, or oth er
in ju ries [2, 3]. Th e average in ju ry severity score o patien ts
w ith open diaph yseal ractu res o th e tibia, em u r, an d h u -
m eru s w as 13.5, 18.1, an d 17.5, respectively [2]. Th ere ore,
it is critical to per orm a th orou gh assessm en t o every patien t
w ith an open ractu re an d to u se appropriate resu scitation
an d m an age oth er in ju ries as n ecessary accordin g to advan ced
trau m a li e su pport protocols.
Evalu ation o th e in ju red extrem ity sh ou ld in clu de a care u l
n eu rovascu lar exam in ation an d assessm en t o th e size, loca-
tion , an d con tam in ation o th e w ou n d ( Fig 8-1 a ). Th e w ou n d
is irrigated, gross con tam in ation rem oved, an d a sterile dress-
in g applied. Th e ractu red extrem ity sh ou ld be grossly
realign ed an d im m obilized w ith a splin t ( Fig 8 -1 b c ). In tra-
ven ou s an tibiotic th erapy sh ou ld be started an d tetan u s
proph ylaxis sh ou ld be given depen din g on th e patien ts
im m u n ization statu s.
Th e treatin g su rgeon sh ou ld be aw are o th e possibility o
com partm en t syn drom e despite th e presen ce o th e open
w ou n d ractu re, especially in cru sh in ju ries [4] ( Fig 8-2 ).
Fractu re ch aracteristics, su ch as articu lar in volvem en t an d
com m in u tion , sh ou ld be evalu ated by th e appropriate im ag-
in g stu dies to plan xation o th e ractu re.
123
 Se ct io n 2Spe cial
situations
8
O pe n
fracture s

a b c d
Fig 8-1 a d Ope n fracture of the tibia and bula with se ve re soft-tissue injury and contam ination.
a Note the fore ign particle s and dirt e m be dde d in the soft tissue s.
b The re is se ve re de form ity of the le g with e xce ssive displace m e nt and malrotation, as can be se e n by e valuating the diffe re nce
in the proje ctions of the kne e and ankle joints. Vascular com prom ise of the e xtre m ity m ay be the re sult of such fracture -site
de formity and this x-ray should not have be e n take n be fore re duction and splinting of the injure d le g.
c Gross re storation of rotation and alignm e nt of the e xtre mity m ay re store pe rfusion and pre ve nt furthe r soft-tissue dam age .
d The fracture was stabilize d intra ope rative ly with an e xte rnal xator. Note the antibiotic polym e thylm e thacrylate be ads in place .

a b c
Fig 8-2a c Patie nt with ope n distal tibial and bular fracture s de ve loping com partm e nt syndrom e of the le g.
a Traum atic wounds associate d with the ope n fracture s.
b The sm alle r traum atic wound was incorporate d into an incision that e xte nde d proxim ally and distally along the poste rior borde r of
the bula to rst de com pre ss all four com partm e nts of the le g and the n pe rform de bride m e nt and irrigation of the ope n fracture s.
c An e xte rnal xator spanning the ankle joint was use d as provisional xation. Whe n not be ing use d for de nitive xation, e xte rnal
xation is place d as a spanning construct le aving the zone of injury fre e of pins and e asily acce ssible for im aging studie s and future
xation. The surge on should also be aware of future incision place m e nt to avoid placing e xte rnal xation pins in the se are as.

124 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Charalampos G Zalavras
2 .2 Cla s s ifica t io n o f o p e n fra ct u re s
Th e severity o th e in ju ry can vary con siderably am on g
patien ts. Classi cation system s o open ractu res h ave been
developed w ith th e aim to describe th e in ju ry, gu ide treat-
m en t, determ in e progn osis, an d com pare treatm en t m eth ods
or research pu rposes.
Th e classi cation system o Gu stilo an d An derson , su bse-
qu en tly m odi ed by Gu stilo, Men doza, an d William s [5, 6],
h as been exten sively u sed an d com prises th e ollow in g types:
Type I: w ou n d o 1 cm or less w ith m in im al con tam i-
n ation or m u scle cru sh in g.
Type II: w ou n d m ore th an 1 cm lon g w ith m oderate
so t-tissu e dam age an d cru sh in g. Bon e coverage is
adequ ate an d com m in u tion is m in im al.
Type IIIA: exten sive so t-tissu e dam age , o ten du e to a
h igh -en ergy in ju ry with a cru sh in g com pon en t. Mas-
sively con tam in ated wou n ds an d severely com m in u ted
or segm en tal ractu res are in clu ded in th is su btype. Bon e
coverage is adequ ate.
Type IIIB: exten sive so t-tissu e dam age w ith periosteal
strippin g an d bon e exposu re, u su ally w ith severe
con tam in ation an d bon e com m in u tion . Flap coverage
is requ ired.
Type IIIC: arterial in ju ry requ irin g repair.
Th e risk o in ection depen ds on th e severity o th e open
ractu re an d ran ges rom 02% or type I open ractu res,
210% or type II, an d 1050% or type III ractu res [5, 7].
How ever, th e reliability o th is classi cation m ay be su bop-
tim al. Bru m back an d Jon es [8] evalu ated th e respon ses o
orth opedic su rgeon s wh o were asked to classi y open ractu res
o th e tibia on th e basis o videotaped case presen tation s,
an d ou n d th at th e average agreem en t am on g observers w as
on ly 60% overall.
Th e Orth opaedic Trau m a Association proposed a n ew clas-
si cation system or determ in in g th e severity o open ractu res,
w h ich is based on path oan atom ical ch aracteristics o th e
in ju ry an d speci cally evalu ates skin , m u scle, an d arterial
in ju ry, bon e loss, an d con tam in ation [9]. Th e average in -
terobserver agreem en t w as 86% overall bu t in terobserver
reliability on m u scle in ju ry an d con tam in ation was m oderate
[10].
Regardless o th e system u sed, classi cation o th e open
ractu re sh ou ld n ot be don e in th e em ergen cy departm en t
bu t in stead in th e operatin g room a ter w ou n d exploration
an d debridem en t. On ly th en can th e treatin g su rgeon assess
th e exten t an d severity o th e in ju ry an d th e degree o con -
tam in ation .
3 An t ib io t ics
3 .1 Sys t e m ic a n t ib io t ic t h e ra p y
Most open ractu re w ou n ds are con tam in ated w ith m icro-
organ ism s [5 , 7 , 1 1 ], th ere ore, an tibiotics are n ot u sed or
proph ylaxis bu t or treatm en t o w ou n d con tam in ation .
An tibiotic th erapy redu ces th e risk o in ection in patien ts
w ith open ractu res. Patzakis et al [11] establish ed th e im -
portan t role o an tibiotics in a prospective ran dom ized stu dy,
w h ich in dicated a decreased in ection rate w h en ce azolin
w as adm in istered be ore debridem en t (2 o 84 ractu res
[2.3% ]) com pared w ith n o an tibiotics (11 o 79 ractu res
[13.9% ]).
An tibiotic adm in istration sh ou ld be started as soon as possible
on adm ission o th e patien t in th e em ergen cy departm en t.
Both an im al an d clin ical stu dies [7, 12] h ave dem on strated
th e im portan ce o early an tibiotic th erapy. Delay o m ore
th an 3 h ou rs rom in ju ry to adm in istration o an tibiotics
h as been associated w ith an in creased risk o in ection [7].
Th e recom m en ded du ration o an tibiotic th erapy is 3 days
[7, 13], alth ou gh a stu dy [14 ] com parin g 1 day to 5 days o
an tibiotics reported sim ilar in ection rates an d su ggested
th at 1 day o an tibiotics m ay be an option . An addition al
3-day adm in istration o an tibiotics is recom m en ded or su b-
sequ en t su rgical procedu res, su ch as repeated debridem en t
an d w ou n d coverage [7, 13 , 15 ].
Open w ou n d cu ltu res are n ot u se u l in selectin g th e optim al
an tibiotic regim en . Cu ltu re resu lts requ ire a con siderable
delay an d th ey o ten ail to iden ti y th e organ ism cau sin g a
su bsequ en t in ection [16, 17]. In m ost cases, in ection s are
n ot cau sed by th e organ ism s in itially presen t in th e w ou n d
bu t by n osocom ial organ ism s, su ch as staph ylococci an d
aerobic gram -n egative bacilli. A ran dom ized con trolled
trial (RCT) [18] reported th at on ly 3 o 17 in ection s (18% )
th at developed in a series o 171 open ractu res w ere cau sed
by an organ ism iden ti ed by th e in itial cu ltu res. Wou n d
cu ltu res obtain ed be ore w ou n d debridem en t are n ot recom -
m en ded [1 7 ]. A ter debridem en t, in traoperative cu ltu res
m ay h elp w ith an tibiotic selection or su bsequ en t procedu res
or or m an agem en t o early in ection s.
A com bin ation o gram -positive coverage (eg, a rst-gen -
eration ceph alosporin su ch as ce azolin ) an d gram -n egative
coverage (eg, an am in oglycoside su ch as gen tam icin ) is
w idely accepted or severe (type III) open ractu res [7, 13,
15, 19, 20]. System ic adm in istration o am in oglycosides m ay
n ot be n ecessary i am in oglycoside-im pregn ated beads are
u sed or local an tibiotic delivery.
125
 Se ct io n 2Spe cial
situations
8
O pe n
fracture s

Adm in istration o a ceph alosporin as a sin gle agen t in types
I an d II open ractu res h as been proposed by som e au th ors,
[13, 19, 20] w h ereas oth ers [7, 15] h ave advocated com bin ed
gram -positive an d gram -n egative coverage or th ese less
severe open ractu res to provide coverage again st con tam -
in atin g gram -n egative organ ism s. Patzakis an d Wilkin s
reported th at in open tibial ractu res, com bin ation th erapy
redu ced th e in ection rate (5 o 109 [4.5% ]) com pared w ith
ceph alosporin on ly (25 o 192 [13% ]) [7]. Fractu re types I
an d II w ere n ot an alyzed separately bu t th e distribu tion o
ractu re types w as com parable betw een th e tw o grou ps.
Moreover, a type IIIA open ractu re w ith a w ou n d o sm all
size m ay be m isclassi ed in th e em ergen cy departm en t as
type I or II open ractu re an d treated w ith a ceph alosporin
on ly ( Fig 8 -3 ).
An aerobic coverage (eg, am picillin or pen icillin ) sh ou ld be
added in in ju ries th at m ay resu lt in con tam in ation w ith
clostridial organ ism s (eg, arm in ju ries) an d in vascu lar in -
ju ries th at can create con dition s o isch em ia an d low oxygen
ten sion to preven t clostridial m yon ecrosis (ie, gas gan gren e).
It is critical to rem em ber th at an tibiotic th erapy is n ot a
su bstitu te or th orou gh su rgical debridem en t.
Th e grow in g em ergen ce o an tim icrobial resistan ce in bac-
teria, an d speci cally th e in crease o m eth icillin -resistan t
Staphylococcus aureus (MRSA), h as raised qu estion s abou t
th e adequ acy o cu rren t an tibiotic protocols. An RCT com -
pared adm in istration o a com bin ation o van com ycin an d
ce azolin to adm in istration o on ly ce azolin in 101 patien ts
w h o w ere ollow ed u p or a m in im u m o 30 days an d or
10 m on th s on average [2 1 ]. A sign i can tly h igh er rate o
MRSA in ection w as observed in patien ts w ith MRSA n asal
colon ization , bu t th ere w as n o di eren ce in th e in ection
rates between th e grou p receivin g van com ycin an d ce azolin
(19% ) versu s th e grou p receivin g on ly ce azolin (15% ).
Th ere was on e MRSA in ection in each grou p [21]. Th e rou tin e
u se o van com ycin in open ractu res can n ot be recom m en d-
ed based on available data an d th e poten tial or em ergen ce
o glycopeptide-resistan t organ ism s is a seriou s con cern .

a b c
Fig 8-3a c Ope n distal fe m oral fracture .
a The sm all size of the wounds around the kne e are a doe s not corre spond to the se ve rity of the
injury.
b c Exte nsive com m inution is pre se nt in this ope n distal fe m oral fracture as can be se e n in the AP ( b )
and late ral (c ) vie ws. This fracture m ay be e rrone ously classi e d as a type I or II inste ad of type IIIA
ope n fracture .

126 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Charalampos G Zalavras
3 .2 Lo ca l a n t ib io t ic t h e ra p y
Local an tibiotic th erapy with an tibiotic-im pregn ated delivery
veh icles h as been u sed in addition to system ic an tibiotic
th erapy [22]. A com m on ly u sed delivery veh icle is polym eth -
ylm eth acrylate (PMMA) cem en t, w h ich can be m olded to
create beads o 510 m m diam eter ( Fig 8-1d ) or spacer blocks
o larger size. Bioabsorbable delivery veh icles, su ch as cal-
ciu m su l ate, appear to be a prom isin g altern ative [23] (see
ch apter 6 Local delivery o an tibiotics an d an tiseptics or
u rth er discu ssion ).
Several an tim icrobial agen ts h ave been su ccess u lly in cor-
porated in to PMMA cem en t or local delivery, in clu din g
am in oglycosides, van com ycin , an d ceph alosporin s [22]. An
an tibiotic appropriate or local delivery m u st be h eat-stable,
available in pow der orm , an d active again st th e targeted
m icrobial path ogen s. In open ractu res, am in oglycosides are
com m on ch oices becau se o th eir broad spectru m o activity,
h eat stability, an d low allergen icity.
Elu tion , w h ich is th e process o release o an tibiotics rom
th e delivery veh icle to th e su rrou n din g tissu es, is determ in ed
by th e di eren ce in th e con cen tration o an tibiotics betw een
th e an tibiotic delivery system an d its en viron m en t. High
con cen tration o an tibiotics an d in creased porosity o th e
delivery veh icle acilitate elu tion [24, 25]. Elu tion depen ds
on th e type o an tibiotic, an d tobram ycin h as su perior elu -
tion properties com pared to van com ycin [26]. A f u id m e-
diu m is n ecessary or elu tion an d th e rate o f u id tu rn over
in f u en ces th e local an tibiotic con cen tration [27 ]. Elu tion o
an tibiotics rom PMMA beads is ch aracterized by an in itial
rapid ph ase an d a secon dary slow ph ase [2 8 ]. Follow in g
in sertion o an tibiotic-im pregn ated PMMA beads in th e open
ractu re w ou n d, th e w ou n d sh ou ld be sealed by a sem iper-
m eable barrier, so th at th e elu ted an tibiotic rem ain s at th e
in volved area to ach ieve a h igh local con cen tration ( Fig 8 -4 ).
Th e an tibiotic bead-pou ch tech n iqu e ach ieves a h igh local
con cen tration o an tibiotics w ith ou t a h igh system ic con -
cen tration , th ereby m axim izin g e cacy at th e in ju ry site
an d m in im izin g toxicity [29 ]. Sealin g o th e w ou n d rom th e
extern al en viron m en t by th e sem iperm eable barrier preven ts
secon dary con tam in ation by n osocom ial path ogen s, estab-
lish es an aerobic w ou n d en viron m en t, an d prom otes patien t
com ort by avoidin g pain u l dressin g ch an ges.
Th e an tibiotic bead-pou ch tech n iqu e h as been sh ow n to
redu ce th e in ection rate w h en u sed in addition to system ic
an tibiotics or m an agem en t o severe open ractu res [30, 31].
Osterm an n et al [30] com pared system ic an tibiotics alon e to
com bin ed treatm en t w ith both system ic an tibiotics an d th e
bead-pou ch tech n iqu e in a series o 1,085 open ractu res.
Th e in ection rate w as sign i can tly redu ced to 31 o 845
ractu res (3.7% ) in th e an tibiotic bead-pou ch grou p com pared
to 29 o 240 ractu res (12% ) in open ractu res treated on ly
w ith system ic an tibiotics. An alysis based on open ractu re
severity dem on strated th at th e redu ction o in ection w as
statistically sign i can t on ly in type III ractu res (6.5% versu s
20.6% ). Note th at w ou n d m an agem en t di ered betw een
th e tw o grou ps. In th e system ic an tibiotic grou p, 63% o
w ou n ds w ere le t open in itially, th ereby predisposin g th e
w ou n d to secon dary con tam in ation . In th e an tibiotic bead
pou ch grou p, 95% o w ou n ds w ere eith er closed prim arily
or sealed w ith th e bead-pou ch tech n iqu e.
Fig 8-4 Antibiotic polym e thylm e thacrylate be ads are in place in the
are a of the soft-tissue de fe ct. Note the se m ipe rm e able m e m brane
dre ssing, which se als the are a to ke e p the uid with e lute d antibiotics
in the wound, while at the sam e tim e maintaining an ae robic wound
e nvironm e nt and pre ve nting se condary contam ination.
127
 Se ct io n 2Spe cial
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8
O pe n
fracture s

4 De b rid e m e n t An tiseptic solu tion s can be toxic to h ost cells an d are n ot

Th orou gh su rgical debridem en t is critical in th e m an agem en t
o open ractu res. Th e qu ality o su rgical debridem en t is n ot
on ly th e m ost im portan t actor in th e treatm en t o osteo-
m yelitis bu t also in th e preven tion o in ection in open ractu res
[32, 33]. Devitalized tissu e an d oreign m aterial prom ote th e
grow th o m icroorgan ism s an d developm en t o bio lm an d
also con stitu te a barrier or th e h osts de en se m ech an ism s.
4 .1 De b rid e m e n t p rin cip le s
Debridem en t sh ou ld be per orm ed in th e operatin g room .
Wh en th e open ractu re w ou n d is in su cien t or detailed
evalu ation o th e in ju ry, su rgical exten sion o th e w ou n d
is n ecessary ( Fig 8-2a -b ). Su rgical exten sion sh ou ld be don e
in a w ay th at respects th e vascu larity o so t tissu es an d
acilitates ractu re xation an d an y an ticipated recon stru c-
tive procedu res. I th e location o a sm all trau m atic w ou n d
is su ch th at an in cision in corporatin g th e w ou n d w ou ld n ot
acilitate su bsequ en t procedu res, a su rgical approach to th e
ractu re can be don e w ith ou t in corporatin g th e trau m atic
w ou n d an d th e open ractu re can be debrided th rou gh th is
approach .
recom m en ded [3 4 ]. Ow en s et al [3 5 ] u sed a goat m odel
in volvin g a com plex m u scu loskeletal w ou n d th at w as in -
ocu lated w ith Pseudomonas aeruginosa to com pare irrigation
w ith n orm al salin e solu tion , bacitracin solu tion , castile soap,
or ben zalkon iu m ch loride ollow in g w ou n d debridem en t.
Alth ou gh n orm al salin e w as associated w ith th e sm allest
redu ction in bacterial cou n ts im m ediately a ter irrigation
(29% o pretreatm en t levels), it w as also associated w ith
th e sm allest rebou n d o bacterial cou n ts at 48 h ou rs (68%
o pretreatm en t levels). In con trast, th e castile soap grou p
h ad th e greatest redu ction in bacterial cou n ts im m ediately
a ter irrigation (13% o pretreatm en t levels) an d also th e
greatest rebou n d o bacterial cou n ts at 48 h ou rs (120% o
pretreatm en t levels).
High -pressu re pu lsatile lavage h as been associated w ith
bacterial seedin g in to th e in tram edu llary (IM) can al in an
an atom ical specim en stu dy [36], w ith in creased w ou n d bac-
terial cou n ts at 48 h ou rs a ter irrigation [35] an d w ith adverse
e ects on early n ew bon e orm ation in a rabbit m odel [37].

Debridem en t sh ou ld be per orm ed in a system atic an d

atrau m atic ash ion w h ile protectin g adjacen t n eu rovascu lar
stru ctu res. Skin an d su bcu tan eou s tissu e are sh arply debrid-
ed back to bleedin g edges. Mu scle is sh arply debrided u n til
on ly viable tissu e is presen t in th e w ou n d. Viable m u scle is
ch aracterized by bleedin g w h en cu t an d con tractility u pon
tou ch in g th e tissu e w ith th e cau tery tip or squ eezin g it w ith
orceps. Bon e ragm en ts sh ou ld be le t in place on ly i th ey
h ave so t-tissu e attach m en ts, in dicatin g vascu larity o th e
ragm en ts. Pu n ctate bleedin g rom exposed bon e su r aces
h elps determ in e viability o th e bon e. Free ragm en ts are
avascu lar an d sh ou ld be rem oved w ith th e exception o
articu lar ragm en ts th at are large en ou gh to be u se u l in
recon stru ction o th e in volved join t. Large ree diaph yseal
ragm en ts can be u sed as a gu ide to assist w ith redu ction o
th e ractu re an d discarded a terw ard bu t sh ou ld n ot be
retain ed.

4 .2 Irriga t io n
Irrigation o th e open ractu re w ou n d ollow in g debridem en t
m ay u rth er m ech an ically rem ove sm all oreign bodies an d
redu ce bacterial con cen tration . Th e au th ors pre eren ce is
gravity irrigation ( Fig 8-5 ). Th e type o solu tion an d its de-
Fig 8-5 The authors pre fe rre d te chnique of gravity irrigation.
livery pressu re rem ain con troversial w ith m ost data derived Note that the saline uid bags have be e n e le vate d as much as
rom in vitro an d an im al stu dies. possible (approxim ate ly 3 m from the oor) using gravity to ge ne rate
pre ssure .

128 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Charalampos G Zalavras
Clin ical data on irrigation o open ractu re w ou n ds are
lim ited. An glen [38] com pared bacitracin solu tion to n on -
sterile castile soap solu tion or irrigation o open ractu res
in an RCT an d ou n d n o di eren ce in in ection an d n on u n ion
rates, bu t an in creased rate o w ou n d-h ealin g problem s w ith
bacitracin . Irrigation w ith n orm al salin e w as n ot evalu ated
in th is stu dy.
A pilot RCT [39] com pared th e e ects o di eren t irrigation
m eth ods (castile soap versu s n orm al salin e an d h igh - versu s
low -pressu re pu lsatile lavage) on th e reoperation rate an d
com plication rate in patien ts with open ractu res. Reoperation
rates a ter a 1-year ollow -u p w ere sim ilar in th e castile soap
grou p (13 o 56 [23% ]) an d th e salin e grou p (13 o 55
[24% ]). In creased reoperation rate w as seen in th e h igh -
pressu re grou p (16 o 57 [28% ]) com pared to th e low-pressu re
grou p (10 o 54 [19% ]) bu t th is w as n ot sign i can t. Note
th at th e sam ple size w as sm all an d th e protocol regardin g
an tibiotics an d w ou n d m an agem en t w as n ot stan dardized
am on g cen ters.
4 .3 Tim in g o f d e b rid e m e n t
Urgen t debridem en t o open ractu res w ith in 6 h ou rs rom
in ju ry h as been con sidered im portan t or preven tion o in -
ection ; h ow ever, th e literatu re h as n ot su pported th is
n otion [7, 4043].
Patzakis an d Wilkin s [7] reported in 1989 th at th e in ection
rate w as sim ilar in open ractu re w ou n ds debrided w ith in
12 h ou rs rom in ju ry (27 o 396 [6.8% ]) an d in th ose de-
brided a ter 12 h ou rs rom in ju ry (50 o 708 [7.1% ]) an d
con clu ded th at elapsed tim e rom in ju ry to debridem en t is
n ot a critical actor or developm en t o in ection in patien ts
receivin g an tibiotic th erapy.
Harley et al [40] dem on strated th at tim e to su rgical debride-
m en t eith er as a con tin u ou s or dich otom ou s (ie, be ore
versu s a ter 8 h ou rs rom in ju ry) variable was n ot associated
w ith in creased in ection or n on u n ion rates. Mu ltivariate
an alysis sh ow ed th at open ractu re severity bu t n ot tim e to
debridem en t w as an in depen den t predictor o in ection an d
n on u n ion .
Skaggs et al [43] dem on strated th at th e rates o acu te in ection
in ch ildren w ith open ractu res w ere sim ilar in th e grou p
th at u n derw en t su rgical m an agem en t w ith in 6 h ou rs (12
o 344 ractu res [3% ]) an d in th e grou p th at u n derw en t
su rgical m an agem en t rom 7 to 24 h ou rs (4 o 202 ractu res
[2% ]). No di eren ce in in ection rates w as ou n d a ter
strati cation o open ractu res accordin g to th e Gu stilo-
An derson classi cation . For type III open ractu res, th e in -
ection rate w as 6 o 61 in th e early grou p (10% ) com pared
to 2 o 36 in th e delayed grou p (6% ).
Pollak et al [41] ou n d n o relation sh ip betw een tim e to su r-
gical debridem en t an d in ection in 307 patien ts w ith severe
open low er extrem ity ractu res. Th e in ection rate w as 28% ,
29% , an d 26% in patien ts w h o u n derw en t debridem en t
earlier th an 5 h ou rs, 510 h ou rs, an d m ore th an 10 h ou rs
rom in ju ry, respectively. In terestin gly, th e tim e betw een
in ju ry an d adm ission to th e de n itive trau m a treatm en t
cen ter w as an in depen den t predictor o th e likelih ood o
in ection .
Alth ou gh bacterial popu lation s in an u n treated con tam in ated
w ou n d in crease over tim e, it appears th at early an tibiotic
adm in istration an d th orou gh su rgical debridem en t can e -
ectively redu ce th e con tam in ation presen t. As a resu lt, sm all
delays in su rgical m an agem en t do n ot appear to tran slate
in in creased in ection rates an d m ay allow or stabilization
an d resu scitation o th e patien t, as w ell as or treatm en t o
th e patien t by experien ced su rgical team s w ith all n ecessary
equ ipm en t available.
4 .4 Se co n d -lo o k d e b rid e m e n t
A sin gle th orou gh debridem en t execu ted by an experien ced
su rgeon m ay be en ou gh , especially in less severe open rac-
tu res, an d th is can be ollow ed by prim ary closu re, eith er
com plete or partial, o th e open ractu re w ou n d (see topic
5 o th is ch apter).
On th e oth er h an d, a repeated debridem en t m ay be per-
orm ed a ter 48 h ou rs based on th e degree o con tam in ation
an d so t-tissu e dam age. In th is case, delayed w ou n d closu re
can be per orm ed w h en th e goal o a clean w ou n d w ith
viable, bleedin g tissu es h as been ach ieved. In in ju ries requ ir-
in g f ap coverage, debridem en t sh ou ld also be repeated at
th e tim e o th e so t-tissu e procedu re.
129
 Se ct io n 2Spe cial
situations
8
O pe n
fracture s

5 Wo u n d clo s u re a n d s o ft-t is s u e co ve ra ge
5 .1 Prim a r y w o u n d clo s u re
Prim ary closu re o open ractu re w ou n ds rem ain s a con tro-
versial topic an d th e optim al tim e or w ou n d closu re is still
debated [44]. Prim ary w ou n d closu re h as tradition ally n ot
been advocated or open ractu res becau se it h as been as-
sociated w ith w ou n d in ection s, in clu din g th e catastroph ic
com plication o gas gan gren e (clostridial m yon ecrosis) th at
n ecessitates am pu tation o th e in volved extrem ity an d m ay
even lead to death o th e patien t [45, 46].
How ever, gas gan gren e h as m ostly com plicated m ilitary
w ou n ds w ith severe tissu e in ju ry, gross con tam in ation , an d
in adequ ate an tibiotic th erapy or debridem en t. Clin ical stu dies
[7, 4749] o civilian in ju ries com parin g prim ary to delayed
closu re h ave n ot sh own an in creased in ection rate ollowin g
prim ary closu re, an d su ggested th at prim ary closu re m ay
preven t secon dary con tam in ation an d redu ce su rgical m or-
bidity, h ospital stay, an d cost [47, 48]. Patzakis an d Wilkin s
[7] reported in 1989 th at prim ary closu re did n ot resu lt in
in creased in ection rate. Speci cally, in ection com plicated
10.6% o w ou n ds closed prim arily com pared to 13.4% o
w ou n ds closed w ith a delay [7]. DeLon g et al [47] reported
th at prim ary closu re w as sa e an d w as n ot associated w ith
an in crease in in ection or n on u n ion , an d a recen t stu dy by
Jen kin son et al [48] sh ow ed a decreased in ection rate w ith
prim ary closu re.
Prim ary closu re o care u lly selected open ractu re w ou n ds
is a viable option u n der th e ollow in g con dition s:
1. Th ere is n o severe so t-tissu e in ju ry, vascu lar in ju ry, or
gross con tam in ation , especially w ith soil or ecal m atter.
2. Early adm in istration o an tibiotics h as taken place.
3. A m eticu lou s debridem en t h as been execu ted by an ex-
perien ced su rgeon resu ltin g in th e presen ce o on ly
h ealth y, bleedin g tissu e in th e w ou n d at th e en d o th e
procedu re.
4. Th e w ou n d edges can be approxim ated w ith ou t ten sion .
Partial w ou n d closu re is an oth er option or less severe
in ju ries [50].
Th e su rgical exten sion o th e w ou n d created to assess th e
bon e an d so t tissu es an d to acilitate debridem en t can be
closed prim arily in types I an d II open ractu res, leavin g
on ly th e in ju ry w ou n d open , to be closed in delayed ash ion .
I th ere is an y dou bt abou t th e viability o th e tissu es an d/
or th e adequ acy o th e debridem en t, th e w ou n d sh ou ld n ot
be closed prim arily an d a secon d-look debridem en t sh ou ld
be u n dertaken w ith th e plan to per orm delayed w ou n d
closu re or a so t-tissu e coverage procedu re, depen din g on
th e statu s o th e so t-tissu e en velope ( Fig 8 -6 ).

Important actors or decision making Initial management Repeat debridement

a. Severity of injury Usually at 48 hours
b. Timing of antibiotics and presentation
c. Adequacy of debridement

Less severe injuries (types I or II)

Limited muscle damage
No vascular injury
No gross contamination, especially with soil/feces Primary wound closure
Early antibiotics
Thorough debridement by experienced surgeon
Closure can be achieved without tension

Less severe injuries (types I or II)

Wound left open
Above conditions not present
and
Repeat debridement and wound closure
Antibiotic bead pouch or
Severe injuries (type IIIA) negative-pressure wound therapy dressing
Soft tissue adequate for bone coverage

Wound left open Repeat debridement and flap at that time

Severe injuries (type IIIB)
and or
Soft tissue no t adequate for bone coverage
Antibiotic bead pouch Repeat debridement and flap within 7 days

Fig 8-6 Algorithm for wound manage m e nt in ope n fracture s.

130 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Charalampos G Zalavras
5 .2 De la ye d w o u n d clo s u re
Delayed w ou n d closu re preven ts an aerobic con dition s in
th e w ou n d an d th e developm en t o clostridial in ection s,
perm its drain age o th e w ou n d, an d allow s tissu es o qu es-
tion able viability to be discovered at th e secon d-look de-
bridem en t. On th e oth er h an d, a repeated su rgical procedu re
is requ ired, resu ltin g in in creased h ospital stay an d h ealth care
costs.
Delayed w ou n d closu re is recom m en ded or m ore severe
in ju ries w ith exten sive so t-tissu e dam age an d gross con -
tam in ation in patien ts presen tin g w ith a con siderable delay,
in w ou n ds w ith tissu es o qu estion able viability at th e en d
o th e debridem en t, an d in w ou n ds th at can n ot be approx-
im ated w ith ou t ten sion .
It sh ou ld be em ph asized th at w h en a decision is m ade to
close th e open ractu re w ou n d w ith a delay, or w h en closu re
is n ot possible an d a so t-tissu e recon stru ctive procedu re is
n eeded, th e w ou n d sh ou ld n ot be le t exposed to th e ou tside
en viron m en t to preven t con tam in ation w ith n osocom ial
path ogen s. In stead th e an tibiotic bead-pou ch tech n iqu e [30]
or n egative-pressu re w ou n d th erapy [51] sh ou ld be u sed.
5 .3 So ft-t is s u e co ve ra ge a n d re co n s t ru ct io n
In th e presen ce o exten sive so t-tissu e in ju ry, as in type
IIIB open ractu res, w h ich preclu des delayed w ou n d closu re
an d adequ ate bon e coverage, so t-tissu e recon stru ction is
requ ired. Local or ree m u scle f aps can be tran s erred to
ach ieve so t-tissu e coverage o th e open ractu re. A vascu lar
so t-tissu e en velope prom otes ractu re h ealin g, en h an ces
an tibiotic delivery, an d ach ieves coverage o th e w ou n d th at
preven ts secon dary con tam in ation as w ell as desiccation o
exposed an atom ical stru ctu res, su ch as bon e, cartilage, an d
ten don s. So t-tissu e recon stru ction is u su ally ach ieved w ith
local or ree tissu e tran s ers depen din g on th e location an d
size o th e so t-tissu e de ect [525 5]. Pollak et al [55] con -
clu ded th at u se o a ree f ap in lim bs w ith a severe osseou s
in ju ry w as associated w ith ew er w ou n d com plication s
n ecessitatin g operative treatm en t com pared to a rotation al
f ap. A m icrovascu lar su rgeon sh ou ld participate early in
m an agem en t o an open ractu re w ith exten sive so t-tissu e
dam age.
So t-tissu e recon stru ction sh ou ld be per orm ed early, with in
th e rst 7 days. Delays beyon d 710 days h ave been associ-
ated w ith in creased rates o in ection an d f ap com plication s
[16, 56]. Godin a [57] even argu ed in avor o f ap coverage
w ith in 72 h ou rs. Gopal et al [54] also u tilized an early ag-
gressive protocol in types IIIB an d IIIC open ractu res an d
observed deep in ection in 4 o 63 ractu res (6% ) th at w ere
covered w ith in 72 h ou rs com pared to 6 o 21 (29% ) in th e
on es covered beyon d 72 h ou rs. It sh ou ld be n oted th at in
th ese stu dies th e an tibiotic bead pou ch w as n ot u sed, an d
th ere ore secon dary con tam in ation m ay h ave been an im -
portan t con ou n din g actor con tribu tin g to th e in ectiou s
com plication s.
131
 Se ct io n 2Spe cial
situations
8
O pe n
fracture s
6 Fra ct u re fixa t io n
6 .1 Fixa t io n o p t io n s
Stable xation w ith restoration o len gth , align m en t, an d
rotation o th e ractu re bon e(s) is an im portan t part o open
ractu re m an agem en t. Stable ixation preven ts u rth er
in ju ry to th e so t-tissu e en velope by u n stable ractu re rag-
m en ts, acilitates w ou n d care, an d perm its early m otion o
adjacen t join ts an d early patien t m obilization an d reh abili-
tation . Fractu re stability also en h an ces th e h ost respon se to
con tam in atin g organ ism s, despite th e presen ce o im plan ts
[58].
Several option s exist or ractu re xation . Fixation can be
de n itive or provision al, an d m eth ods in clu de IM n ailin g,
extern al xation , an d plate xation . Selection am on g th ese
option s depen ds on care u l evalu ation o bon e, so t tissu e,
an d patien t ch aracteristics [15]. More th an on e m eth od m ay
be applicable to a speci c in ju ry an d th e su rgeon s expertise
an d availability o im plan ts sh ou ld also be con sidered.
6 .2 In t ra m e d u lla r y n a ilin g
In tram edu llary n ailin g is an e ective an d com m on ly u sed
tech n iqu e or xation o diaph yseal ractu res o th e low er
extrem ity ( Fig 8 -7 ) [59 61 ]. Statically in terlocked IM n ailin g
m ain tain s len gth an d align m en t o th e ractu red bon e, is
biom ech an ically su perior to oth er m eth ods, an d does n ot
in ter ere w ith so t-tissu e m an agem en t. How ever, it disru pts
a b
Fig 8-7 a b Ope n se gm e ntal fracture of the tibia and bula ( a )
tre ate d with an intram e dullary nail ( b ).
132
th e en dosteal bon e circu lation to a variable degree, depen din g
on ream in g o th e m edu llary can al.
Ream ed IM n ailin g is com m on ly u sed or open diaph yseal
ractu res o th e em u r w ith good resu lts. A stu dy [6 1 ] on
ream ed IM n ailin g or th ese ractu res reported n o in ection s
in 62 types I, II, an d IIIA open ractu res o th e em u r an d 3
in ection s in 27 type IIIB open ractu res (11% ) [61].
Ream ed an d u n ream ed IM n ailin gs h ave been u sed or open
diaph yseal ractu res o th e tibia. Ream ed n ailin g com pro-
m ises th e en dosteal blood su pply m ore th an u n ream ed
n ailin g bu t vascu larity is gradu ally recon stitu ted [62 , 63 ].
Ream in g also acilitates in sertion o larger diam eter IM n ails,
th ereby im provin g ractu re-site stability.
Th ree ran dom ized trials [6466] com parin g ream ed to u n -
ream ed n ailin g or open tibial ractu res did n ot dem on strate
a sign i can t di eren ce in in ection rates. Keatin g et al [64]
reported th at th e in ection rate w as 1 o 40 (2.5% ) in th e
u n ream ed n ailin g grou p com pared to 2 o 45 (4.4% ) in th e
ream ed n ailin g grou p. Fin kem eier et al [65] reported in ection
rates o 1 o 26 (3.8% ) an d 1 o 19 (5.3% ) in th e u n ream ed
an d ream ed n ailin g grou p, respectively. Ream ed n ailin g
resu lted in ew er screw ailu res in both stu dies. A m u lticen ter
RCT [66] com parin g ream ed to u n ream ed n ailin g in 400 open
tibial ractu res did n ot sh ow an y sign i can t di eren ces in
th e reoperation rate or in ection (19 o 206 [9.2% ]) in
ream ed n ailin g versu s 16 o 194 (8.2% ) in u n ream ed n ail-
in g) or in th e overall reoperation rate. Th e optim al n ailin g
tech n iqu e or open ractu res o th e tibia rem ain s u n certain .
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Charalampos G Zalavras
6 .3 Ext e rn a l fixa t io n
Extern al xation can be applied in a tech n ically easy, sa e,
an d expedien t w ay, w ith m in im al blood loss. For th is reason
it can be ben e cial in dam age-con trol situ ation s, su ch as
type IIIC open ractu res to ach ieve prom pt ractu re stabili-
zation , an d in u n stable polytrau m a patien ts to m in im ize
an y addition al in f am m atory an d ph ysiological bu rden
cau sed by su rgery [67, 68].
Extern al xation preserves th e vascu larity o th e ractu re
site an d avoids im plan t in sertion at th e zon e o in ju ry. Th ere-
ore, it m ay be u se u l in w ou n ds w ith severe so t-tissu e
dam age an d gross con tam in ation , as in type IIIB open rac-
tu res ( Fig 8-1 d ) [69 71 ]. Extern al xation can be u sed as th e
de n itive xation m eth od or open diaph yseal ractu res o
th e tibia w ith good resu lts [6971].
Tw o prospective ran dom ized stu dies [59, 60], w h ich com pared
extern al xation to IM n ailin g as de n itive xation o open
tibial ractu res, ou n d n o di eren ces in in ection an d n on -
u n ion rates [59, 60]. In stead, th ese com plication s w ere as-
sociated w ith in creased severity o th e open ractu re [59].
How ever, extern al xation requ ires patien t com plian ce an d
is o ten com plicated by pin -track in ection s an d ractu re
m alalign m en t i rem oved prem atu rely [59, 72].
b c
a
Fig 8-8a c Ope n fracture of the proxim al tibia and bula ( a ),
stabilize d with a locking plate ( b c ).
Delayed con version o extern al xation to IM n ailin g h as
been associated w ith h igh in ection rates o 4450% [16 , 7 3 ].
How ever, early con version o th e xator to a n ail w ith in 2
w eeks an d in th e absen ce o pin -track in ection appears to
be sa e [74, 75].
Extern al xation can also be u se u l as provision al xation
in open periarticu lar ractu res ( Fig 8 -2 c ) [76]. A join t-span n in g
extern al xator can stabilize th e ractu re, restore len gth ,
align m en t, an d rotation o th e in volved bon e an d can be
ollow ed by de n itive xation at a secon d stage. Rin g xators
m ay also be u sed or th e de n itive treatm en t o periarticu lar
ractu res w ith lim ited in tern al xation as n eeded [77, 78].
6 .4 Pla t e a n d s cre w fixa t io n
Plate an d screw xation is u se u l in in traarticu lar an d m e-
taph yseal ractu res becau se it allow s an atom ical redu ction
an d restoration o join t con gru en cy. It can be per orm ed as
de n itive early xation [7 9], or it can ollow provision al
stabilization o th e ractu re w ith a span n in g extern al xator
[76]. Cu rren t lockin g plate design s an d m in im ally in vasive
tech n iqu es h ave proved u se u l or th e ch allen gin g in ju ries
o open periarticu lar ractu res ( Fig 8 -8 ) [8 0 , 8 1 ]. Plate an d
screw xation is recom m en ded or open diaph yseal ractu res
o th e orearm an d h u m eru s u n less th ere is severe m u scle
dam age an d m assive con tam in ation [82, 83].
133
 Se ct io n 2Spe cial
situations
8
O pe n
fracture s
7 Ma n gle d e xt re m it y
Salvage o a severely in ju red extrem ity ( Fig 8 -9 ) h as been
acilitated by su rgical an d m edical advan ces bu t despite m u l-
tiple recon stru ctive procedu res, u n ction al recovery o a
severely in ju red extrem ity m ay be lim ited w ith associated
m orbidity, prolon ged h ospitalization s, psych ological distress,
an d n an cial dem an ds [84].
For th is reason salvage o every m an gled extrem ity, espe-
cially wh en a vascu lar in ju ry is presen t, alth ou gh tech n ically
possible, m ay be a disservice to th e patien t [85]. Th e altern a-
tive o below -kn ee am pu tation h as even been con sidered
as a su perior altern ative, leadin g to aster recovery an d
redu ced lon g-term disability in com parison w ith su ccess u l
lim b salvage [84 ].
Fig 8-9 Mangle d lowe r e xtre m ity with a type IIIC ope n fracture
of the tibia and bula with se ve re m uscle dam age and bone
com m inution.
134
A prospective observation al m u lticen ter stu dy (Low er Ex-
trem ity Assessm en t Project) evalu atin g lim b-th reaten in g
low er extrem ity in ju ries in civilian s provided u se u l in or-
m ation abou t th e lon g-term u n ction al ou tcom e o th ese
in ju ries [8688]. Bosse et al [86] reported th at patien ts w h o
u n derw en t am pu tation h ad u n ction al ou tcom es th at w ere
sim ilar to th ose o patien ts w h o u n derw en t lim b salvage at
2 years. Th e Sickn ess Im pact Pro le score w as 12.6 in th e
am pu tation grou p versu s 11.8 in th e lim b salvage grou p an d
th e ou tcom e rem ain ed sim ilar betw een th e tw o grou ps
a ter adju stin g or patien t an d in ju ry ch aracteristics. Retu rn
to w ork at 2 years w as sim ilar in th e lim b salvage grou p
(49% ) an d th e am pu tation grou ps (53% ). How ever, lim b
salvage com pared to am pu tation w as associated w ith a
sign i can tly h igh er rate o repeated h ospitalization s or
com plication s (48% versu s 34% , P = .002) an d reoperation s
(19% versu s 5% , P < .001). Fu n ction al ou tcom e w as ad-
versely a ected by several actors u n related to th e in ju ry,
su ch as low edu cation al level, n on w h ite race, poverty, lack
o private h ealth in su ran ce, poor social su pport n etw ork,
low sel -e cacy, sm okin g, an d in volvem en t in litigation
[86].
MacKen zie et al [88] dem on strated th at disability ollow in g
severe low er extrem ity trau m a persisted at 7 years a ter th e
in ju ry. Approxim ately h al th e patien ts w h o u n derw en t
eith er lim b salvage or am pu tation h ad su bstan tial disability
at 7 years w ith n o di eren ce in u n ction al ou tcom es betw een
th e tw o grou ps. Reh ospitalization betw een 2 an d 7 years
rom in ju ry w as requ ired in 39% o patien ts w h o u n derw en t
lim b salvage an d in 33% o patien ts w h o u n derw en t am -
pu tation [88].
Th e decision to am pu tate or proceed w ith lim b salvage o a
n on viable extrem ity w ith a type IIIC open ractu re or a
m an gled extrem ity w ith a type IIIB ractu re is o ten di cu lt
an d h as im portan t m edical, psych ological, an d socioeco-
n om ic im plication s. Th e treatin g su rgeon con ron ted w ith
th e dilem m a o salvage versu s am pu tation sh ou ld evalu ate
an d con sider several patien t an d extrem ity actors. Patien t
actors in clu de age, associated in ju ries, cardiopu lm on ary
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Charalampos G Zalavras
an d h em odyn am ic statu s, preexistin g m edical problem s,
u n ction al requ irem en ts, an d socioecon om ic su pport. Ex-
trem ity actors in clu de th e previou s u n ction al statu s o th e
extrem ity an d actors determ in ed by th e severity o in ju ry,
su ch as th e exten t o vascu lar in ju ry, th e tim e o w arm
isch em ia, th e degree o so t-tissu e an d bon e dam age, an d
an atom ical disru ption o th e tibial n erve. Note th at loss o
plan tar sen sation u pon presen tation , w h ich w as con sidered
an im portan t adverse progn ostic actor or lim b salvage, is
n ot associated w ith a w orse u n ction al ou tcom e o lim b
salvage at 2 years com pared to presen ce o a sen sate oot
[89]. In act, m ore th an h al th e patien ts presen tin g w ith an
in sen sate oot regain ed sen sation at 2 years [89].
Specialized scorin g system s, su ch as th e Man gled Extrem ity
Severity Score (MESS), h ave been developed in an e ort to
o er gu idelin es or decision m akin g in lim b-th reaten in g
low er extrem ity in ju ries [90]. How ever, a prospective eval-
u ation o th e Man gled Extrem ity Severity Score (MESS) th e
Lim b Salvage In dex (LSI) th e Predictive Salvage In dex (PSI)
as w ell as th e Nerve In ju ry, Isch em ia, So t-Tissu e In ju ry,
Skeletal In ju ry, Sh ock, an d Age o Patien t Score (NISSSA)
an d th e Han n over Fractu re Scale-97 (HFS-97) did n ot su p-
port th e u tility o an y o th ese scores or di eren tiatin g
betw een extrem ities likely to be salvaged su ccess u lly an d
th ose requ irin g am pu tation [91]. Th ere ore, scores at or above
th e am pu tation th resh old sh ou ld n ot be relied u pon to m ake
a decision or am pu tation . On th e oth er h an d, low scores
can predict th e poten tial or lim b salvage.
Th e n al decision sh ou ld be an in dividu alized on e, based
on detailed evalu ation o th e patien t an d th e extrem ity,
sou n d ju dgm en t, an d discu ssion with th e patien t an d am ily
i easible [92].
8 Co n clu s io n
Open ractu res are ch allen gin g in ju ries, wh ich are associated
w ith a progressively in creased risk or in ection , n on u n ion ,
an d even am pu tation , depen din g on th eir severity. Patien ts
w ith open ractu res sh ou ld be evalu ated or associated an d
poten tially li e-th reaten in g in ju ries. Th e in volved extrem ity
sh ou ld be evalu ated or n eu rovascu lar in ju ry an d com part-
m en t syn drom e, an d th e severity o con tam in ation , so t-
tissu e dam age, an d bon e in ju ry sh ou ld be determ in ed,
pre erably in traoperatively. System ic an tibiotic th erapy
sh ou ld be in itiated u pon patien t presen tation an d local
an tibiotic delivery u sin g an tibiotic PMMA beads m ay be
added in severe in ju ries. Th orou gh debridem en t w ith re-
m oval o all devitalized tissu e an d oreign bodies is a critical
actor or preven tion o in ection . Prim ary w ou n d closu re
is an option or less severe in ju ries i on ly h ealth y, viable
tissu e is presen t in th e wou n d a ter a m eticu lou s debridem en t
per orm ed by an experien ced su rgeon . Delayed closu re w ith
a secon d-look debridem en t a ter 48 h ou rs is recom m en ded
or m ore severe in ju ries. At th at tim e th e w ou n d can be
closed i possible. In th e case o exten sive so t-tissu e in ju ry,
a ree or local f ap m ay be requ ired. In ection s in open rac-
tu res u su ally resu lt rom secon dary con tam in ation w ith
n osocom ial organ ism s; th ere ore, th e open ractu re w ou n d
sh ou ld n ot be le t exposed bu t in stead covered u sin g th e
bead-pou ch tech n iqu e or n egative-pressu re w ou n d th erapy.
De n itive or provision al stable xation o th e open ractu re
sh ou ld be ach ieved. Th e tim in g an d tech n iqu e o xation
depen d on bon e, so t-tissu e, an d patien t ch aracteristics, an d
on th e su rgeon s expertise. Prin ciple-based m an agem en t o
open ractu res w ill h elp ach ieve th e goals o in ection pre-
ven tion , ractu re u n ion , an d restoration o u n ction o th e
in ju red extrem ity.
135
 Se ct io n 2Spe cial
situations
8
O pe n
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e t a l. Ran dom ized trial o ream ed an d
u n ream ed in tram edu llary n ailin g o
tibial sh a t ractu res. J Bone Joint Surg
Am. 2008 Dec;90(12):25672578.
67. Ro b e r t s CS, Pa p e HC, Jo n e s AL, e t a l.
Dam age con trol orth opaed ics: evolvin g
con cepts in th e treatm en t o patien ts
wh o h ave su stain ed orth opaed ic
trau m a. Instr Course Lect. 2005;54:
4 47462.
68. Pa p e HC, To rn e t t a P, 3rd , Ta rkin I, e t a l.
Tim in g o ractu re xation in
mu ltitrau m a patien ts: th e role o early
total care an d dam age con trol su rger y.
J Am Acad Orthop Surg. 20 09
Sep;17(9):541549.
69. Ed w a rd s CC, Sim m o n s SC, Bro w n e r BD,
e t a l. Severe open tibial ractu res.
Resu lts treatin g 202 in ju ries w ith
extern al xation . Clin Orthop Relat
Res.1988 May;(230):98 115.
70. Be h re n s F, Se a rls K. Extern al xation o
th e tibia. Basic con cepts an d
prospective evalu ation . J Bone Joint Surg
Br. 1986 Mar;68(2):24 6 254.
71. Ma rs h JL, Ne p o la JV, Wu e s t TK, e t a l.
Un ilateral extern al xation u n til
h ealin g w ith th e dyn am ic axial xator
or severe open tibial ractu res. J Orthop
Trauma.1991;5(3):34134 8.
72. Bh a n d a ri M, Gu ya t t GH, Sw io n t ko w s k i
MF, e t a l. Treatm en t o open ractu res
o th e sh a t o th e tibia. J Bone Joint
Surg Br. 2001 Jan ;83(1):6268.
73. McGra w JM, Lim EV. Treatm en t o open
tibial-sh a t ractu res. Extern al xation
an d secon dary in tram edu llary n ailin g.
J Bone Joint Surg Am. 1988
Ju l;70(6):900 911.
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8
O pe n
fracture s
74. Bla ch u t PA, Me e k RN, OBrie n PJ.
Extern al xation an d delayed
in tram edu llar y n ailin g o open
ractu res o th e tibial sh a t. A
sequ en tial protocol. J Bone Joint Surg
Am. 1990 Ju n ;72(5):729 735.
75. Sca le a TM, Bo s w e ll SA, Sco t t JD, e t a l.
Extern al xation as a bridge to
in tram edu llar y n ailin g or patien ts
w ith mu ltiple in ju ries an d w ith emu r
ractu res: dam age con trol orth opedics.
J Trauma. 2000 Apr;48(4):613 621;
d iscu ssion 621613.
76. Sirkin M, Sa n d e rs R, DiPa s q u a le T, e t a l.
A staged protocol or so t tissu e
m an agem en t in th e treatm en t o
com plex pilon ractu res. J Orthop
Trauma. 1999 Feb;13(2):78 8 4.
77. To rn e t t a P, 3rd , We in e r L, Be rgm a n M,
e t a l. Pilon ractu res: treatm en t w ith
com bin ed in tern al an d ex tern al
xation . J Orthop Trauma.
1993;7(6):489 496.
78. Wa t s o n JT. High -en ergy ractu res o th e
tibial plateau . Orthop Clin North Am.
1994 Oct;25(4):723 752.
79. Be n irs ch ke SK, Agn e w SG, Ma yo KA,
e t a l. Im m ed iate in tern al xation o
open , com plex tibial plateau ractu res:
treatm en t by a stan dard protocol.
J Orthop Trauma. 1992;6(1):78 86.
80. Kre go r PJ, St a n n a rd JA, Zlo w o d zk i M,
e t a l. Treatm en t o d istal emu r
ractu res u sin g th e less invasive
stabilization system : su rgical
experien ce an d early clin ical resu lts in
103 ractu res. J Orthop Trauma. 2004
Sep;18(8):509 520.
138
81. St a n n a rd JP, Wils o n TC, Vo lga s DA,
e t a l. Th e less in vasive stabilization
system in th e treatm en t o com plex
ractu res o th e tibial plateau : sh ort-
term resu lts. J Orthop Trauma. 2004
Sep;18(8):552 558.
82. Mo e d BR, Ke lla m JF, Fo s t e r RJ, e t a l.
Im m ed iate in tern al xation o open
ractu res o th e d iaphysis o th e
orearm . J Bone Joint Surg Am. 1986
Sep;68(7):1008 1017.
83. Va n d e r Grie n d R, To m a s in J, Wa rd EF.
Open redu ction an d in tern al xation o
h u m eral sh a t ractu res. Resu lts u sin g
AO platin g tech n iqu es. J Bone Joint Surg
Am. 1986 Mar;68(3):430 433.
8 4. Ge o rgia d is GM, Be h re n s FF, Jo yce MJ,
e t a l. Open tibial ractu res w ith severe
so t-tissu e loss. Lim b salvage com pared
w ith below-th e-kn ee am pu tation .
J Bone Joint Surg Am.1993
Oct;75(10):143114 41.
85. Ha n s e n ST, Jr. Th e type-IIIC tibial
ractu re. Salvage or am pu tation . J Bone
Joint Surg Am. 1987 Ju l;69(6):799 80 0.
86. Bo s s e MJ, Ma cKe n zie EJ, Ke lla m JF,
e t a l. An an alysis o ou tcom es o
recon stru ction or am pu tation a ter
leg-th reaten in g in ju r ies. The New
England journal o medicine. 2002 Dec;
347(24):1924 1931.
87. Ma cKe n zie EJ, Bo s s e MJ. Factors
in f u en cin g ou tcom e ollow in g
lim b-th reaten in g lower lim b trau m a:
lesson s learn ed rom th e Lower
Extrem ity Assessm en t Project (LEAP).
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No.):S205 210. Review.
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88. Ma cKe n zie EJ, Bo s s e MJ, Po lla k AN,
e t a l. Lon g-term persisten ce o
disability ollow in g severe lower-lim b
trau m a. Resu lts o a seven -year
ollow-u p. J Bone Joint Surg Am. 2005
Au g;87(8):18011809.
89. Bo s s e MJ, McCa r t h y ML, Jo n e s AL, e t a l.
Th e in sen sate oot ollow in g severe
lower extrem ity trau m a: an in d ication
or am pu tation ? J Bone Joint Surg Am.
2005 Dec;87(12):26012608.
90. Jo h a n s e n K, Da in e s M, Ho w e y T, e t a l.
Objective criteria accu rately pred ict
am pu tation ollow in g lower extrem ity
trau m a. J Trauma. 1990
May;30(5):568 572; d iscu ssion
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91. Bo s s e MJ, Ma cKe n zie EJ, Ke lla m JF,
e t a l. A prospective evalu ation o th e
clin ical u tility o th e lower-extrem ity
in ju ry-severity scores. The Journal o
bone and joint surgery American volume.
2001 Jan ;83-A(1):3 14.
92. To rn e t t a P, 3rd , Ols o n SA. Am pu tation
versu s lim b salvage. Instr Course Lect.
1997; 46:511518.
Ste phe n L Kate s, Olivie r Bore ns
Martin A McNally
9.1 In fe ctio n a fte r fra ctu re
Martin A McNally
1 Ba s ics
Su ccess u l ractu re care in volves th e preven tion an d treatm en t
o com plication s w h ich m ay arise du rin g th e ractu reh ealin g
period. In ection rem ain s a seriou s problem a ter ractu re,
particu larly w ith th e in creasin g u se o in tern al xation . Th e
attem pted salvage o previou sly u n treatable open lim b
in ju ries w ith bon e loss, severe con tam in ation , an d m ajor
so t-tissu e de ects h as provided a n ew grou p o patien ts w ith
ch allen gin g in ection s an d in ected n on u n ion s.
Ou r con cepts o im plan t-related in ection are ch an gin g w ith
a better u n derstan din g o th e com plex in teraction s betw een
m icroorgan ism s, im plan t su r aces, an d h ost im m u n ity. We
are n ow am iliar w ith th e bio lm approach to th e m an -
agem en t o in ection a ter prosth etic join t im plan tation
[13]. In in ection a ter ractu re, treatm en t con cepts are m ore
varied an d less well de n ed. Most stu dies report sm all coh orts
w ith a sin gle treatm en t m odality. It is di cu lt to com pare
treatm en ts an d to de n e strategies or an y speci c patien t
grou p. How ever, th e prin ciples o eradication o in ection
a ter ractu re h ave m an y sim ilarities to th e treatm en t o
prosth etic join t in ection . Th e decision s arou n d reten tion
or rem oval o an im plan t, th e m an agem en t o th e so t tissu es
an d th e provision o local an d system ic an tim icrobial th erapy
are com m on to both clin ical situ ation s.
1.1 Et io lo g y a n d in cid e n ce
It is rare or a n on operatively treated closed ractu re to
becom e in ected. Most in ection a ter ractu re occu rs a ter
an open in ju ry or a ter in tern al xation . Th u s, in ection
a ter ractu re is m ain ly exogen ou s w ith con tam in ation oc-
cu rrin g at th e tim e o in ju ry or du rin g su rgical in terven tion .
Th is o ers an im portan t opportu n ity to preven t in ection
w ith appropriate early w ou n d debridem en t, stabilization ,
an d proph ylactic an tibiotics (see ch apter 4 Preven tion o
in traoperative in ection an d ch apter 8 Open ractu res).
Occasion ally, a ractu re in ection m ay develop lon g a ter
ractu re xation an d h ealin g, as a resu lt o h em atogen ou s
spread in a bacterem ic patien t. Th is sh ou ld be su spected in
th ose w ith a com prom ised im m u n e system w h o presen t
w ith a pain u l h ealed ractu re th at w as previou sly pain ree.
Th e in ciden ce o in ection a ter ractu re is depen den t on th e
severity o th e bon y lesion , th e dam age to th e so t-tissu e
en velope, an d th e Gu stilo-An derson type [4]. In open rac-
tu res, in ection occu rs u n com m on ly in Gu stilo-An derson
type I ractu res at 02% bu t rises to 210% or type II, an d
to 1050% or type III in ju ries [5 ]. Open ractu res o th e
tibia are tw ice as likely to becom e in ected as sim ilar grade
in ju ries to oth er bon es [6].
139
 Se ct io n 2Spe cial
situations
9.1Infe ction
after
fracture
Fractu res o th e pelvic rin g can h ave h igh rates o deep
in ection , eith er as a resu lt o open in ju ries w ith con tam in a-
tion or com plicatin g th e m eth od o xation . Posterior xation
o sacral an d type C u n stable ractu res carry a 10% deep
in ection risk [7]. Overall, pelvic rin g ractu res h ave a 7%
risk (211% ) regardless o th e m eth od o treatm en t [8]. Wh en
a pelvic extern al xator is u sed, th e reported pin in ection
rates vary rom 2.5% to 50% [8, 9]. Pin -site in ection m ay
h ave seriou s con sequ en ces w ith pin loosen in g an d loss o
ractu re redu ction .
Acetabu lar ractu res are u su ally closed in ju ries bu t arou n d
39% w ill su er deep in ection a ter treatm en t [1 0]. Th is
rate m ay be h igh er in open in ju ries an d in th ose w ith severe
closed in tern al deglovin g o th e so t tissu es (ie, Morel-
Lavall lesion ) [11 ]. Th e u se o postoperative irradiation to
redu ce th e in ciden ce o h eterotopic ossi cation m ay also
in crease th e in ection rate [12]. Deep in ection a ter acetab-
u lar ractu re w ill resu lt in h ip join t destru ction in over h al
o cases w ith requ irem en t or m ajor staged recon stru ction
or am pu tation [10, 13].
In ection rates m ay also be h igh in ractu res in volvin g th e
oot. Th is h igh risk o in ection m ay be related to redu ced
blood su pply in diabetic patien ts an d th ose w ith periph eral
vascu lar disease, or to th e prevalen ce o cru sh in ju ries to
th e so t tissu es w h ich o ten accom pan y oot ractu res. Open
in ju ries h ave th e h igh est likelih ood o developin g an in ection .
In on e series o 36 open calcan eal ractu res treated w ith
in tern al xation , 60% o th ose w ith ractu re com m in u tion
(type III ractu res) w ere com plicated by osteom yelitis [14].
Oth er stu dies h ave con rm ed th e h igh in ection rates in
open ractu res. Even w ith early aggressive debridem en t,
so t-tissu e recon stru ction an d im m ediate an tibiotics, an
in ciden ce o arou n d 419% can be expected [1 5, 16 ]. Th e
in ection risk is m ost closely related to th e degree o so t-tissu e
in ju ry [16].
Local actors arou n d th e ractu re are im portan t bu t it h as
also been sh ow n th at th e gen eral h ealth o th e patien t con -
tribu tes to in ection risk an d ou tcom e rom treatm en t o
establish ed in ection . Th e presen ce o on e or tw o m edical
com orbidities in creases th e risk o in ection in open ractu res
by alm ost th ree tim es w h ile th ree or m ore com orbidities
in crease th e risk by ve to six tim es [17]. Tobacco sm okin g
alon e sign i can tly in creases in ection rate an d tim e to u n ion
in open tibial ractu res [18].
140
1.2 Pa t h o ge n e s is
Fractu res are n orm ally in ected by bacteria livin g in h igh ly
organ ized colon ies, attach ed to th e su r ace o im plan ts, rag-
m en ts o dead bon e, or poorly vascu larized so t tissu es. Bac-
teria in th e plan kton ic state are qu ickly recogn ized by th e
h ost im m u n e de en ces. In th is state, th ey are m etabolically
active an d can be eradicated by cellu lar or h u m oral h ost
respon ses in th e extracellu lar space. Most an tibiotics w h ich
act on protein syn th esis path w ays or n u clear division are
active again st plan kton ic bacteria.
With exposu re o bon e in an open ractu re or du rin g op-
erative xation , th e su r ace is in itially con tam in ated by
bacteria w h ich rapidly adh ere to th e su r ace by a series o
com plex in teraction s, in volvin g bacterial cell w all protein s
kn ow n as adh esin s. With in a sh ort period, th e bacteria
secrete a polysacch aride extracellu lar m atrix (glycocalyx)
in w h ich th ey can su rvive w ith redu ced m etabolic activity
(station ary state) [19, 20]. Th is com plex stru ctu re o bacterial
colon ies in polysacch aride is kn own as bio lm (see ch apter 1
Im plan t-associated bio lm ). With in bio lm s, bacteria h ave
in creased organ ism to organ ism sign alin g (qu oru m sen sin g)
w h ich acilitates u rth er developm en t o th e bio lm . Th ey
can also break ree (em igration ) an d travel elsew h ere or
betw een segm en ts o th e bio lm , en h an cin g in teraction s
an d alterin g bacterial beh avior [21].
Th e presen ce o oreign m aterial in th e tissu es greatly in -
creases th e risk o clin ical in ection an d redu ces th e in ocu lu m
requ ired to create an in ection [20]. Th ere is also eviden ce
th at m etal im plan ts m ay cau se alteration o th e n orm al h ost
im m u n e cell respon se, w ith im paired gran u locyte u n ction
on th e su r ace o im plan ts an d in h ibition o T-cell activation
an d plasm a cell u n ction [21].
Th is poten t com bin ation o isolation w ith in th e bio lm , very
low m etabolic activity, an d im paired h ost im m u n e respon se,
allow s bacteria to evade eradication an d becom e m u ch m ore
resistan t to an tim icrobial th erapy [20, 23]. It h as also been
sh ow n th at som e organ ism s (particu larly Staphylococcus
aureus) can in vade h ost cells an d su rvive in side osteoblasts.
Th is m ay be on e cau se o later recu rren ce o in ection , lon g
a ter treatm en t [24].
It is im portan t to u n derstan d th at m ost ractu re im plan t
in ection s occu r w ith bacteria in bio lm s [2, 20], so cu rative
treatm en t o th ese m u st in volve rem oval o th e bio lm . Th e
m ech an ism s described above m ean th at establish ed ractu re
in ection s are very u n likely to be eradicated w ith an tibiotics
alon e [25].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Martin A McNally

1.3 His t o p a t h o lo g y 1.4 Cla s s ifica t io n o f in fe ct io n a ft e r fra ct u re

Th e h istological eatu res o in ection a ter ractu re are ch ar-
acterized by th e presen ce o bon e n ecrosis w ith su rrou n din g
in f am m atory respon se. Bon e death m ay be a resu lt o th e
in itial in ju ry, th e su rgical approach to xation , or th erm al
in ju ry du e to drillin g an d ream in g w ith blu n t or h igh -speed
drills [26]. Th e in ection can also kill bon e by secreted toxin s,
th rom bosis o n u trien t vessels an d by cortical bon e strippin g
du e to su bperiosteal abscess orm ation .
Dead bon e w h ich rem ain s in con tin u ity w ith th e livin g bon e
(su ch as an exposed tip o cortex at th e en d o a diaph yseal
ractu re ragm en t) can be revascu larized by creepin g su b-
stitu tion i it does n ot becom e in ected. On ce bacteria are
adh eren t to th e dead bon e; th e dead bon e w ill eith er be
separated rom th e livin g diaph ysis, orm in g a sequ estru m
or w ill be resorbed by m acroph age activity. A loose dead
ractu re ragm en t can n ot be revascu larized. It m ay be sh ed
ou t o th e lim b th rou gh a sin u s or m ay becom e en cased in
n ew bon e orm ation (ie, in volu cru m ) ( Fig 9.1-1 ). Gen erally,
th is n ew bon e is w ell vascu larized an d is resistan t to colo-
n ization by bacteria. It w ill on ly orm i th ere is livin g
periosteu m over th e in ected area.
De n in g su bgrou ps w ith in a disease or con dition is on ly
u se u l i th is adds to ou r u n derstan din g o th e con dition or
h elps to su ggest m eth ods o treatm en t or each su bgrou p.
Th e cu rren t classi cation s h ave been developed m ostly
arou n d lon g bon e osteom yelitis [27 ] an d prosth etic join t
in ection [28 ]. Th ese h ave sign i can t om ission s an d lim ita-
tion s. For exam ple, th e m ost requ en tly u sed classi cation ,
Ciern y-Mader [27], m akes n o re eren ce to th e so t tissu es or
to th e m icrobiology o th e in ection . Th e on ly stu dy attem pt-
in g to classi y th e so t-tissu e elem en ts w as pu blish ed in 1977,
be ore th e m ain advan ces in plastic su rgical cover o in -
ected bon e an d so t-tissu e de ects [29 ]. A recen t attem pt to
produ ce a m ore com preh en sive classi cation o all bon e an d
join t in ection s h as collated seven eatu res o th e patien ts
an d th e in ection [30].

1
4

2
3

Fig 9.1-1 This m agne tic re sonance

imaging scan shows all of the pathological
fe ature s of oste omye litis afte r intram e dullary
nailing of a fe m oral fracture . The re is ce ntral
de ad bone lining the m e dullary canal ( 1 ),
a se parate cortical se que strum ( 2 ), a sinus
track e xte nding to the skin surface ( 3 ), and
pe rioste al ne w bone form ation around the
fe m ur (4 ).

141
 Se ct io n 2Spe cial
situations
9.1Infe ction
after
fracture

Classi cation based on th e tim in g o th e on set (presen tation )
o th e in ection is a u se u l con cept. In ection s a ter ractu re
can be divided in to early (on set w ith in 2 w eeks o ractu re),
delayed (on set betw een 310 w eeks a ter ractu re), an d
late (on set m ore th an 10 w eeks a ter ractu re) [2 5 , 3 1 ]
( Ta b le 9.1-1 ). Th e rapid diagn osis o an early in ection can be
preven ted by in appropriate em piric u se o an tibiotics in th e
rst ew w eeks a ter ractu re, delayin g th e on set o sym ptom s
an d sign s.
Th e speed at w h ich an in ection presen ts a ter in ju ry or
xation can be greatly a ected by so t-tissu e cover. In ection
ollow in g xation o su per cial bon es (eg, olecran on , lateral
m alleolu s, patella) w ill o ten presen t rapidly w ith obviou s
skin breakdow n or w ou n d leakage in a w ell patien t. Deep
in ection arou n d an in tram edu llary n ail or plate xation o
th e proxim al em u r m ay presen t later a ter a period o
in creasin g pain . Th e patien t m ay exh ibit system ic sym ptom s
o ever or m alaise bu t th e su rgical w ou n d m ay appear w ell
h ealed w ith ew local sign s o in ection .
It is im portan t to distin gu ish between an early acu te in ection
an d a later ch ron ic in ection . In acu te in ection , th ere m ay
be lim ited am ou n ts o dead bon e an d th e in itial ractu re
xation m ay be stable. Th is situ ation can be treated prom pt-
ly, w ith ou t com plex procedu res, an d in m an y cases w ill
resu lt in a good ou tcom e w ith a h ealed ractu re. In ch ron ic
in ection , th e presen ce o m icroorgan ism s or a prolon ged
period will be associated with establish ed bio lm , dead tissu e,
an d o ten ractu re in stability w ith xation ailu re. Th is is a
m ajor com plication w h ich w ill requ ire expert treatm en t in
all cases to ach ieve u n ion w ith ou t persisten t in ection [25].

Initial presentation Clinical eatures Microbiology Treatment principle

Early Local pain, erythema, swelling, poor
wound healing, systemic symptoms
Up to 2 weeks after fracture or internal
fixation
Delayed Insidious onset of symptoms
Persistent pain
310 weeks after fracture or internal fixation Impaired bone healing
Early loosening of implants
Late (a) Acute symptoms due to new
hematogenous infection of an implant (rare)
More than 10 weeks after fracture or internal
fixation (b) Chronic symptoms with pain, instability,
wound breakdown, and sinus formation
Virulent organisms Rapid diagnosis
S aureus Salvage of stable fixation before failure
Gram-negative bacilli Debridement with attention to soft tissues
Group Astreptococci Targeted antimicrobial therapy
Low-virulence organisms Individual treatment needed
Coagulase-negative staphylococci, skin May involve exchange of fixation, major
flora bony resection, soft-tissue reconstruction,
and prolonged antibiotic treatment
(a) S aureus and Escheria coli Depends on degree of fracture healing
(b) Often polymicrobial. May be the result
of poorly treated early or delayed infection
producing resistant strains.

Ta b le 9 .1-1 Classi cation of infe ction afte r fracture , by tim ing of initial pre se ntation.

142 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Martin A McNally

1.4 .1 Cie rn y-Ma d e r cla ssifica tio n
Th e Ciern y-Mader classi cation o osteom yelitis [27] describes
tw o essen tial com pon en ts o bon e in ection w h ich are
relevan t to in ected ractu res. First, th e localization o th e
dead or in ected bon e, an d secon d, th e m edical state o th e
patien t. It is predom in an tly u se u l in ch ron ic in ection s.
Th e con tribu tion o th e h ealth o th e patien t can n ot be over-
em ph asized in th e m an agem en t o in ected ractu res. Th e
Ciern y-Mader classi cation divided patien ts in to th ree grou ps
depen din g on ph ysiological h ealth . Grou p A patien ts h ave
n o m edical con dition s w h ich w ou ld im pair th e n orm al
respon se to stress, trau m a or in ection , or w ou n d h ealin g.
Grou p B patien ts h ave com orbidities w h ich eith er a ect th e
local con dition s in th e lim b (preven tin g adequ ate w ou n d
h ealin g) or a ect th e gen eral h ealth o th e in dividu al.
Grou p C patien ts m ay be eith er too rail to u n dergo de n itive
treatm en t or m ay h ave ew sym ptom s rom th e in ection ,
th ereby m akin g exten sive su rgery u n likely to resu lt in an
im provem en t in qu ality o li e.
In in ected ractu res, it is com m on to n d you n g h ealth y
in dividu als w ith severe open in ju ries (Grou p B w ith local
com prom ise) or elderly patien ts w ith m u ltiple com orbidities
in clu din g periph eral vascu lar disease an d diabetes m ellitu s
(Grou p B w ith system ic an d local com prom ise). In con trast
to ch ron ic h em atogen ou s osteom yelitis, th ere are very ew
in ected ractu res w h ich are asym ptom atic an d can be le t
u n treated.
In a stu dy o 1,651 patien ts w ith ch ron ic in ection treated
w ith lim b salvage protocols, Ciern y an d DiPasqu ale [3 3 ]
sh ow ed th at in ection w as eradicated in 96% o Grou p A
h osts bu t on ly 73% o com prom ised Grou p B h osts. Th is
h igh ligh ts th e n eed to u lly assess th e patien t an d to optim ize
gen eral h ealth , prior to begin n in g treatm en t. Ta b le 9 .1-2 lists
som e o th e con dition s w h ich can in ter ere w ith n orm al
w ou n d h ealin g an d th e respon se to su rgery.
Th e oth er elem en t o th e Ciern y-Mader classi cation is th e
an atom ical localization o th e in ection w ith in th e bon e.
Th ey described ou r distin ct pattern s o bon e in volvem en t.

Local actors in the limb (BL host) Systemic actors (BS host)
Arterial ischemia Malnutrition

Venous insufficiency Diabetes

Previous surgery Smoking

Deep vein thrombosis IVdrug abuse

Lymphoedema Bleeding diathesis

Radiation fibrosis Hypoxia

Tissue scarring Renal/liver failure

Retained foreign material/implants Immunosuppression

Osteoporosis Malignancy

Compartment syndrome Sickle cell disease

Obesity Drug inhibitors*

Mental illness

Ta b le 9 .1-2 Conditions which im pact the outcom e of tre atm e nt of

oste omye litis by affe cting wound he aling.
Abbre viations: BL, host with local com prise in the lim b; BS, host with
syste mic com promise; IV, intrave nous.
*
Eg, ste roids, cytotoxic drugs, dise ase -m odifying antirhe um atic drugs,
which m ay inhibit wound he aling or produce imm une com prom ise .

143
 Se ct io n 2Spe cial
situations
9.1Infe ction
after
fracture
In type I, m edu llary osteom yelitis, th e dead bon e is con n ed
to th e m edu llary can al an d en dosteu m ( Fig 9 .1-2 , Fig 9 .1-3 ).
Th ere m ay be sign i can t areas o dead can cellou s bon e bu t
th e w h ole circu m eren ce o th e cortex is alive w ith n orm al
periosteal attach m en t. Th e su rrou n din g so t tissu es are
in tact an d th ere is n o sin u s orm ation . Th ere m ay be over-
lyin g so t-tissu e eryth em a an d edem a. Th is type o in ection
is rare a ter trau m a as it u su ally ollow s h em atogen ou s spread
o bacteria to th e m edu llary can al.
In type II, su per cial osteom yelitis, th e dead bon e is produ ced
by a devascu larization o th e ou ter su r ace o th e cortical
bon e. Th is can ollow so t-tissu e in ju ry su ch as a pretibial
deglovin g w ou n d or bu rn or a ter bon e exposu re in th e base
Fig 9 .1-2 Cie rny-Made r type I: m e dullary
oste omye litis. The infe ction ( pale gre e n)
is con ne d to the m e dullary canal ( 1 )
with no de ad cortical bone ( gre y) and
intact pe rioste um around the bone
( gre e n dashe d line).
Fig 9.1-4 Cie rny-Made r supe r cial
oste omye litis (type II). The de ad
bone ( brown), ( 1 ) is con ne d to the
corte x ofte n with a major ove rlying
soft-tissue de fe ct.
144
o a pressu re u lcer or area o ven ou s stasis ( Fig 9.1-4 , Fig 9.1-5 ,
Fig 9.1-6 , Fig 9 .1-7 ).
In type III, localized osteom yelitis, th ere is in volvem en t o
th e cortex an d u n derlyin g m edu llary bon e. How ever, th is
occu rs in a stable segm en t w ith a region o h ealth y, livin g
bon e bridgin g across th e in ected area. Th is is th e m ost com -
m on orm o in ection in h ealed ractu res w ith late presen -
tation ( Fig 9 .1-8 , Fig 9 .1-9 ). Th e dead bon e m ay be th e resu lt
o ractu re ragm en ts w h ich h ave lost blood su pply du rin g
in ju ry or in tern al xation an d h ave becom e bu ried in callu s.
It is tem ptin g to assu m e th at in ection a ter in tram edu llary
n ailin g w ill be a type I in ection an d in ection a ter platin g
w ill be a type II in ection bu t u su ally th ey are both type III.
Fig 9.1-3 T1 m agne tic re sonance
im age of Cie rny-Made r m e dullary
oste omye litis (type I) showing
high signal from the m e dullary
canal but normal corte x and no
e xte nsion into the soft tissue s.
The re is a ce ntral se que strum ( 1 ).
Fig 9.1-5 The se que strum is e asily se e n in
the m iddle of a large are a of unstable skin from
pre vious skin grafts.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Martin A McNally
Fig 9.1-6 The m agne tic re sonance
imaging shows the unaffe cte d
m e dullary canal with a norm al
nutrie nt arte ry, but m agne tic
re sonance im aging is ofte n unable
to cle arly de m onstrate de ad cortical
bone in type II infe ctions.
Fig 9.1-8 Cie rny-Made r localize d
oste omye litis (type III). The re is
involve me nt of the m e dullary and
cortical bone , ofte n with e xte nsion
into the soft-tissue s and sinus
discharge from the skin.
Fig 9.1-7 Cie rny-Made r
oste omye litis (type II) with
visible cortical se que strum
on the ante rior surface of
the tibia. Plain x-ray de ne s
the se que strum we ll.
2
3
Fig 9.1-9 Magne tic re sonance
im aging of Cie rny-Made r
oste omye litis (type III) of lowe r
tibia afte r intram e dullary nailing.
The re is obvious e ndoste al
se que stration ( 1 ) and de bris (a
cance llous bone se que strum) ( 2 )
within the m e dullary canal. The re
is a we ll-form e d sinus through the
corte x to the skin ( 3 ).
145
 Se ct io n 2Spe cial
situations
9.1Infe ction
after
fracture
In type IV, di u se osteom yelitis, th ere is segm en tal in volve-
m en t w ith dead cortex an d m edu lla across th e en tire cross
section o th e bon e. Th ere is o ten in stability an d su bperi-
osteal abscess orm ation , strippin g th e ou ter su r ace o th e
cortex an d produ cin g u rth er cortical bon e death ( Fig 9 .1-10 ,
Fig 9 .1-11 ). All u n h ealed, in ected ractu res an d in ected
n on u n ion s are type IV. In early in ection s, th e zon e o bon e
death w ill be lim ited to ractu re edges an d to devascu larized
bon e ragm en ts bu t in late presen tin g cases an d establish ed
1
Fig 9.1-10 Cie rny-Made r diffuse
oste omye litis (type IV). The re is de ad
cortical and m e dullary bone ( brown)
e xte nding across the whole bone
diam e te r. Subpe rioste al stripping by
absce sse s ( 1 ) cause furthe r bone
de ath and e xte nsion of the infe ction.
146
in ected n on u n ion s, th e in ection m ay h ave spread th rou gh -
ou t th e m edu llary can al an d adjacen t cortex.
Th e Ciern y-Mader-type in ection can be in erred rom th e
h istory an d n din gs on im agin g bu t sh ou ld be con rm ed
du rin g su rgery. A type III localized in ection m ay h ave very
little h ealth y bridgin g bon e. Adequ ate resection in th ese
cases m ay produ ce a segm en tal de ect, con vertin g th e case
to a type IV.
Fig 9.1-11 This com pute d
tom ographic scan of an infe cte d
Schatzke r VI proxim al tibial fracture
shows the are as of se que ste re d
de ad bone ( 1 ) within ne w bone
form ation ( 2 ) in a Cie rny-Made r type
IV oste omye litis.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Martin A McNally

1.5 Cla s s ifica t io n b y m e t h o d o f fixa t io n
Th e distribu tion o dead bon e an d h en ce in ection in a ractu re
is determ in ed by th e ractu re con gu ration , th e m eth od o
xation , an d th e so t-tissu e disru ption . In a typical Gu stilo-
An derson type IIIB tibial ractu re [4] ( Fig 9 .1-12 ), th ere w ill
be devitalized en ds o th e bon e rom periosteal strippin g. I
th ere is ragm en tation , som e o th e ragm en ts m ay h ave lost
all con n ection w ith th e so t tissu e an d w ill be dead. Oth ers
m ay retain a sm all periosteal attach m en t an d so w ill h ave
som e poten tial to resist in ection an d allow bon e h ealin g.
It h as been n oted th at xation w ith plates, in tram edu llary
n ails an d extern al xator pin s produ ces distin ct pattern s o
bon e n ecrosis, w h ich are predictable an d are h elp u l in
plan n in g excision an d recon stru ction [26, 32].

a b c
Fig 9.1-12a c This ope n diaphyse al fracture has had a de gre e of pe rioste al stripping producing are as
of poorly pe rfuse d or de ad bone (ce ntral brown bone). Ove r se ve ral we e ks, ne w bone de ve lops in vital
re gions (crosse s) but has not be e n able to fully re vascularize the tips of the ce ntral fragm e nts. The se de ad
zone s offe r a surface for bio lm form ation afte r bacte rial colonization. If the patie nt pre se nts late with an
infe cte d nonunion, the location of the de ad bone can be pre dicte d from the initial fracture patte rn. It can
be se en that over time, the main infe cte d bone tends to be come centralize d within ne w bone formation [26 ].

147
 Se ct io n 2Spe cial
situations
9.1Infe ction
after
fracture

1.5 .1 In fe ctio n a fte r p la te o ste o s yn th e sis I exten sive periosteal strippin g h as been per orm ed du rin g
A plate can on ly be placed on th e su r ace o a bon e by dis- ractu re redu ction an d xation , th ere m ay be w idespread
ru ptin g th e so t-tissu e en velope an d periosteu m coverin g in ection , passin g arou n d th e w h ole bon e w ith th e poten tial
th e bon e. Even percu tan eou s platin g th rou gh sm all in cision s or a segm en tal osteom yelitis (Ciern y-Mader type IV)
w ill cau se som e periosteal strippin g an d devascu larization ( Fig 9.1-13 , Fig 9 .1-14 ).
o th e u n derlyin g cortex. With good stability an d in th e
absen ce o bacteria, sm all areas o dead cortical bon e w ill Th e addition o cerclage w ires arou n d plates (or n ails) risks
be rem odeled by creepin g su bstitu tion . How ever, w h en segm en tal cortical devascu larization .
bacteria con tam in ate th e area, th ere is abu n dan t su r ace
available or colon ization an d bio lm orm ation . In ection
w ill spread alon g im plan ts an d becom e establish ed on dead
ragm en ts an d on bon e su r aces w ith ou t periosteal cover.

3 1 3

1
2

Fig 9.1-13 Afte r plating, Fig 9.1-14 This poorly xe d

infe ction will de ve lop on tibial fracture de m onstrate s the
are as of de ad bone unde r de vascularization se e n afte r injury
the plate (1 ), in nonvital and xation. The late ral side of the
fracture fragm e nts ( 2 ), distal fragme nt has be e n strippe d of
around e m pty scre w hole s pe rioste um ( 1 ) which has produce d
( 3 ), and in are as of the rm al ne w bone away from the surface
ne crosis (4 ). of the tibia ( 2 ). The distal tibial
corte x shows no bone formation.
Conve rse ly, the proxim al tibia has
abundant pe rioste al bone form ation
on the late ral side ( 3 ).

148 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Martin A McNally

1.5 .2 In fe ctio n a fte r in tra m e d u lla ry n a ilin g
Closed redu ction an d in tram edu llary n ailin g lim its th e
extraosseou s so t-tissu e in ju ry arou n d a ractu re bu t cau ses
n ew en dosteal devascu larization . Un ream ed an d ream ed
n ails both produ ce en dosteal bon e death , bu t th is w ill be
in creased by overream in g sm all m edu llary can als or ream in g
w ith blu n t ream ers, produ cin g th erm al n ecrosis o cortical
bon e.
Ream in g also gen erates bon e debris rom th e m edu llary
can cellou s bon e, w h ich is pu sh ed ou t th rou gh th e ractu re
site. With ou t in ection , th is m ay act like an au togen ou s
bon e gra t an d aid ractu re h ealin g. Wh en an in ection oc-
cu rs, th is collection o tin y dead bon e ragm en ts will act as
m u ltiple sequ estra or bacterial adh eren ce an d can orm a
su bperiosteal abscess arou n d th e ractu re site ( Fig 9.1-15 ).
Open redu ction , prior to n ailin g, w ill h ave all o th e disad-
van tages o exposu re an d periosteal strippin g togeth er w ith
en dosteal cortical n ecrosis. Th e presen ce o th e open
ractu re w ith dead bon e in creases th e risk o deep in ection
an d n on u n ion .
Wh en an in tram edu llary n ail becom es in ected, th e bacteria
w ill u su ally colon ize all o th e n ail an d lockin g screw s, an d
an y areas o dead cortical bon e adjacen t to th e n ail. Ou tside
th e bon e, periosteal n ew bon e orm ation m ay allow callu s
bridgin g an d ractu re h ealin g, even in th e presen ce o in -
tram edu llary n ail osteom yelitis.

1
4

4
2
2
3
1

a b
Fig 9.1-15 a b De ad bone is se e n ce ntrally around
the nail (1 ) and at the fracture site ( 2 ). Re am ings in the
fracture he m atom a can act as sm all se que stra in the
pre se nce of infe ction ( 3 ). Ofte n, an infe cte d fracture will
continue to he al with pe rioste al ne w bone form e d on
the he althy e xte rior of the corte x (4 ).

149
 Se ct io n 2Spe cial
situations
9.1Infe ction
after
fracture

1.5 .3 In fe ctio n a fte r e xte rn a l fixa tio n
In gen eral, a correctly applied extern al xator allow s ractu re
stabilization w ith ou t an y distu rban ce o th e blood su pply
arou n d th e ractu re (beyon d th at cau sed by th e in ju ry), bu t
in ection arou n d extern al ixator pin sites is com m on .
Exten sion o pin in ection to th e ractu re site is in requ en t
i th e xator h as been placed w ith pin s ou tside th e zon e o
in ju ry.
Early in ection can start rom th e tim e o xator application
du e to th erm al bon e n ecrosis produ ced by drillin g w ith blu n t
drills or h igh -speed drills. Th e correct drill size m u st be u sed
or each pin diam eter. Du rin g pin placem en t, an adequ ate
skin in cision m u st be m ade to avoid cru sh in g th e skin edge
du rin g drillin g or pin passage. Su ch skin cru sh in g is a poten t
cau se o early pin -site in ection s ( Fig 9.1-16 ).
Late pin in ection s are u su ally a resu lt o pin loosen in g or
so t-tissu e in ection s arou n d th e pin , allow in g in gress o
bacteria. In ten sion ed n e-w ire xators (Ilizarov rin g x-
ators), loss o w ire ten sion du rin g treatm en t can allow
m ovem en t at th e bon e in ter ace an d pin osteom yelitis.
It can be seen th at it is possible to de n e th e pattern o
in ection arou n d ractu res an d to classi y grou ps o patien ts.
Care u l in vestigation o th ese issu es w ill give th e clin ician
a better u n derstan din g o each case be ore treatm en t is
started. Failu re to eradicate in ection is o ten a ref ection o
a ailu re to appreciate th e path ogen esis o in ection in an y
given patien t.

a b
Fig 9.1-16 a b With e xte rnal xation, de ad bone is se e n around the pin site s ( 1 ) which m ay
provoke pin loose ning ( 2 ), and at the fracture site in nonvital fragm e nts ( 3 ).

150 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Martin A McNally
2 Dia gn o s t ics
Th ere is n o blood test or im agin g procedu re w h ich w ill
alw ays distin gu ish an in ected ractu re rom a n orm al h eal-
in g ractu re or aseptic n on u n ion . Th e de n itive diagn osis
o an in ection is m ade on a grou p o eatu res (clin ical,
h em atological, m icrobiological, an d im agin g). How ever, th e
presen ce o a drain in g sin u s rom th e ractu re site or th e
laboratory cu ltu re o m icroorgan ism s rom m u ltiple, sterile,
deep sam ples are path ogn om on ic o an in ected ractu re.
2 .1 Clin ica l d ia gn o s is
Th e presen ce o an in ection a ter a ractu re sh ou ld be
su spected w h en th ere is local pain , sw ellin g, eryth em a, or
ten dern ess arou n d th e ractu re an d im paired wou n d h ealin g.
In addition , patien ts m ay eel u n w ell w ith ever, m alaise,
an orexia, an d tach ycardia. Th ere m ay be a h istory o recen t
illn ess or in ection in an oth er body site. Patien ts w ith poly-
trau m a w h o h ave been treated in in ten sive care u n its m ay
h ave sign i can t respiratory an d u rin ary tract in ection s
w h ich can predispose to early ractu re in ection .
It can be seen th at in th e early ph ase a ter an in ju ry, th e
local clin ical eatu res o an in ection in th e lim b m ay be very
sim ilar to th ose o a ractu re h em atom a or even a deep vein
th rom bosis. How ever, i th ere is in creasin g acu te in f am -
m ation arou n d th e ractu re, an in ection sh ou ld be su s-
pected an d early in terven tion u n dertaken .
Th e m ost im portan t eatu re in in ected ractu res is th e
appearan ce o th e w ou n d. A h ealth y ractu re w ou n d sh ou ld
becom e dry w ith in a ew days an d th e su rrou n din g redn ess
an d sw ellin g o in ju ry an d su rgery sh ou ld be gradu ally
im provin g over 710 days. An y deviation rom th is sh ou ld
raise con cern abou t in ection . Wou n d breakdow n w ith
disch arge o f u id can represen t th e release o a ractu re
h em atom a bu t th ese cases h ave a h igh risk o bein g in -
ected or developin g an in ection in th e open w ou n d. In all
cases, th e w ou n d sh ou ld be addressed su rgically ( Fig 9 .1-17 ).
Fig 9.1-17 This patie nt had inte rnal xation of a bular fracture .
The wound re m aine d re d and swolle n with m inor le akage of uid
ove r a 4 -we e k pe riod. This was re gularly dre sse d by a com m unity
nurse and was diagnose d as a supe r cial wound infe ction. Oral
ucloxacillin was give n by the fam ily doctor. At 6 we e ks afte r injury,
the wound ope ne d and discharge d copious pus. The patie nt was
syste mically unwe ll with pyre xia and malaise . The de lay in tre ating
this e arly fracture infe ction cause d loose ning of the xation plate and
pre ve nte d an e arly de bride m e nt and re te ntion of the im plant with
good diagnostic sam pling and appropriate antibiotic the rapy.
151
 Se ct io n 2Spe cial
situations
9.1Infe ction
after
fracture
2 .2 La b o ra t o r y t e s t s
In th e rst ew days a ter ractu re or xation su rgery, th e
C-reactive protein (CRP) level, wh ite blood cell cou n t, an d
eryth rocyte sedim en tation rate (ESR) w ill all be elevated.
With in 12 w eeks, th e CRP sh ou ld be retu rn in g to n orm al
in m ost in dividu als so a persisten t elevation w ith a h igh
w h ite blood cell cou n t in a patien t w ith clin ical sign s o in -
ection can con rm th e diagn osis o an early acu te in ection .
In later presen tin g cases, a previou sly n orm al blood screen
m ay becom e abn orm al bu t m an y patien ts do n ot develop a
sign i can t rise in in f am m atory m arkers. Also, in patien ts
w ith ch ron ic disch arge rom an osteom yelitic segm en t, th ere
m ay be very little system ic reaction an d com pletely n orm al
blood in dices are presen t [20 ].
Rou tin e blood cu ltu re is n ot n orm ally diagn ostic in in ected
ractu res bu t w h en an u n w ell patien t presen ts w ith h igh
ever, blood cu ltu res sh ou ld be taken prior to givin g paren -
teral an tibiotics. Th is cu ltu re m ay be th e on ly opportu n ity
to obtain a m icrobiological diagn osis in th e absen ce o
an tim icrobials [25].
1
2
Fig 9.1-18 This infe cte d ope n tibial fracture de ve lope d bone
loss unde r the m iddle third of the plate and around the e dge s
of the fracture ( 1 ). The late ral side of the fracture has living
bone with good pe rioste al ne w bone form ation above and
be low the fracture . The two scre ws above the fracture show
m ajor loose ning ( 2 ) but the othe r scre ws have no obvious
bone lysis around the m . The se change s progre sse d ove r 10
we e ks from the initial injury.
152
2 .3 Im a gin g s t u d ie s
2 .3 .1 Pla in x-ra ys
Serial plain radiology m ay be h elp u l in iden ti yin g areas o
progressive bon e lysis an d loosen in g arou n d ractu re xation
devices ( Fig 9 .1-18 ). Rapid in crease in bon e lysis is u su ally
du e to in ection . It is alw ays im portan t to com pare later
x-rays w ith th e origin al ractu re lm an d th e im m ediate
postoperative lm . See ch apter 7 Diagn ostics or addition al
in orm ation .
A ter in ju ry, disu se o th e lim b w ill produ ce in creasin g
osteopen ia u n til u ll w eigh t bearin g is restored. Osteopen ia
can on ly develop in bon e w h ich is w ell vascu larized. Areas
o cortex w h ich rem ain w ith in creased den sity (o ten w ron g-
ly described as sclerotic) despite su rrou n din g osteopen ia are
u su ally avascu lar ( Fig 9.1-19 ).
Plain x-rays can n ot de n itively diagn ose or exclu de in ection
as m an y o th e sign s are n ot speci c to ractu re in ection .
Fig 9.1-19 This ope n fracture occurre d above a pre vious hindfoot
fusion. An e arly infe ction de ve lope d and was tre ate d by washout
and antibiotic suppre ssion. At 12 we e ks, the fracture is he aling and
the surrounding bone is showing the usual oste ope nia which occurs
afte r injury. The ce ntral de vascularize d fragm e nt re m ains without
oste ope nia (1 ), con rm ing that it is de ad.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Martin A McNally

2 .3 .2 Ultra so n o gra p h y 2 .3 .3 Co m p u te d to m o gra p h y

Ultrason ograph y is h elp u l in detectin g join t e u sion s an d
f u id collection s arou n d im plan ts. It m ay be u sed to obtain
gu ided aspiration o collection s in su spected early in ection s
to distin gu ish h em atom a rom in ection .
Com pu ted tom ograph y (CT) is u se u l in de n in g th e exten t
o bon e n ecrosis an d in plan n in g excision su rgery. It is par-
ticu larly good or dem on stratin g sm all sequ estra an d areas
o n ew bon e orm ation on viable cortex ( Fig 9.1-11 , Fig 9.1-20a ).
It is less good at visu alizin g th e so t tissu es w ith stu las. Th e
presen ce o m etal im plan ts degrades th e CT im ages bu t n ew
m etal arti act redu ction so tw are (MARS) can redu ce th is
problem . With th e adven t o m agn etic reson an ce im agin g
(MRI), th e u se o con trast w ith CT is rarely in dicated.

a b
Fig 9.1-20a b Com pute d tom ography of this infe cte d distal tibial fracture . It shows the
large ce ntral se que strum , which is not e asily se e n on the plain x-ray ( 1 ). It also shows
the are as of he althy pe rioste um and e ndoste al ne w bone form ation on the surface of the
distal fragm e nt ( 2 ).

153
 Se ct io n 2Spe cial
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9.1Infe ction
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2 .3 .4 Ma gn e tic re so n a n ce im a gin g
In patien ts w ith ou t m etal im plan ts, MRI is th e im agin g m o-
dality o ch oice or th e diagn osis o bon e in ection . It gives
excellen t visu alization o th e so t tissu es. It dem on strates
sequ estra (alth ou gh n ot as w ell as CT), cloacae in th e cortex,
m edu llary abscesses, periosteal in volu cru m , an d su bperios-
teal collection s ( Fig 9.1-6 , Fig 9.1-9 , Fig 9 .1-21 , Fig 9 .1-22 ). It is
n ot good at distin gu ish in g dead cortex rom livin g bon e.
Magn etic reson an ce im agin g w ill also ten d to overestim ate
th e exten t o bon e in ection du e to edem a in th e m edu llary
can al an d so t tissu es. Also, th e MRI appearan ce o in ected
an d u n in ected n on u n ion s can be very sim ilar.
2 1
a b
Fig 9.1-21 a b This radial fracture he ale d afte r inte rnal xation
de spite active infe ction. Re m oval of the plate without ade quate
bone e xcision allowe d oste om ye litis to continue . The m agne tic
re sonance im aging shows the se que ste re d cortical bone (1 )
and the e xte nt of the m e dullary involve m e nt. It cle arly shows
that the distal m e dulla is norm al and that the infe ction has
be e n lim ite d to the fracture site by the form ation of a he althy
bar of e ndoste al ne w bone (m e dullary involucrum) ( 2 ).
154
2 .3 .5 Nu cle a r im a gin g
A w ide ran ge o n u clear scan s h ave been advocated or th e
diagn osis o bon e in ection s [34], bu t gen erally th ey h ave
little to add in th e diagn osis o ractu re-related in ection . In
th e early stages a ter in ju ry, isotope scan s are n on speci c
an d in later cases, MRI w ith or w ith ou t CT w ill give h igh er
resolu tion im agin g. Th e com bin ation o a n u clear scan w ith
a CT scan m ay allow im proved resolu tion an d better an a-
tom ical de n ition o in ection ( Fig 9.1-22 ).
In cases presen tin g w ith pain at a ractu re m an y m on th s or
years a ter in ju ry, a n orm al isotope bon e scan m ay reassu re
th e patien t th at in ection is u n likely.
More recen tly, positron -em ission tom ograph y (PET) or PET
w ith CT h as been advocated in th e diagn osis o in ected
im plan ts [35 ]. Th e adm in istration o radiolabelled glu cose
( 18 FDG) w ith PET an d CT can be u se u l in patien ts w h o h ave
h ad n u m erou s su rgical procedu res. Glu cose is taken u p very
actively by ph agocytes in th e in ected area an d th is can be
iden ti ed by th e PET an d localized by CT. See ch apter 7
Diagn ostics or addition al in orm ation .
Fig 9.1-22 Single -photon e m ission com pute d tom ography with
supe rim pose d x-ray com pute d tom ography (SPECT/ CT) scan of
a chronically infe cte d tibial fracture pre viously tre ate d with an
intram e dullary nail, showing high uptake in the distal tibia with good
localization around a m e dullary cavitary de fe ct.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Martin A McNally
2 .4 Micro b io lo gica l d ia gn o s is
Cu ltu re o path ogen ic organ ism s rom sterile sam ples taken
rom arou n d th e ractu re rem ain s th e de n itive diagn ostic
test. Th is is an essen tial step to con rm diagn osis an d to
gu ide appropriate an tim icrobial th erapy a ter su rgery.
Su per cial sw abs sh ou ld be avoided as th ey give u n repre-
sen tative an d m isleadin g m icrobiological resu lts. Material
or cu ltu re can be obtain ed rom percu tan eou s biopsy bu t
deep sam ples taken at su rgery are recom m en ded [2 5, 36].
Five or six clean , deep sam ples sh ou ld be taken rom arou n d
th e in ected zon e. Each sam ple sh ou ld be h arvested w ith a
separate in stru m en t to avoid cross-con tam in ation an d
sam ples (an d in stru m en ts) sh ou ld n ot tou ch th e patien ts
skin . Sam ples or h istological assessm en t sh ou ld also be
taken in parallel w ith th e m icrobiological tissu e [25 ].
I possible, all biopsies an d deep sam ples sh ou ld be taken
w h en th e patien t h as been taken o an tibiotics or at least
2 w eeks to im prove th e yield o cu ltu red organ ism s.
Son ication o rem oved im plan ts h as been advocated to
disru pt bio lm an d im prove diagn ostic accu racy. Th is h as
been evalu ated in prosth etic join t in ection [37] bu t h as n ot
been sh ow n to in crease accu racy o diagn osis in early im plan t
in ection s [38 ]. It is valu able in situ ation s w h ere th ere is
little m aterial or sam plin g. In in ected ractu res o ph alan ges
or sm all bon es, sm all tissu e sam ples an d rem oved screw s or
w ires su bjected to son ication m ay give reliable diagn osis.
155
 Se ct io n 2Spe cial
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9.1Infe ction
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fracture
3 Tre a t m e n t o f in fe ct e d fra ct u re s
E ective treatm en t o all in ected ractu res is depen den t on
several im portan t prin ciples [39]:
Preoperative:
Optim ization o th e gen eral h ealth o th e patien t
Fu ll discu ssion o treatm en t option s, poten tial
com plication s, an d realistic ou tcom es
Diagn ostic tests or gen eral h ealth an d con dition o
th e lim b
In traoperative:
Represen tative, u n con tam in ated deep sam plin g or
m icrobiology an d h istology
Debridem en t an d excision o dead an d com prom ised
tissu e
Bon e stabilization (reten tion or replacem en t o
in ected im plan ts)
Delivery o an tim icrobial th erapy a ter sam plin g
(local an d system ic)
Man agem en t o dead spaces
So t-tissu e cover
Postoperative:
Early u n ction al reh abilitation
Con tin u ed, cu ltu re-speci c an tim icrobial th erapy
Mon itorin g or early detection o com plication s
Staged secon dary recon stru ction or m alu n ion , join t
con tractu re, an d n on u n ion
Delivery o th ese prin ciples alw ays requ ires th e com bin ed
e orts an d skills o orth opedic trau m a su rgeon s, in ectiou s
disease ph ysician s, radiologists, an d plastic su rgeon s w h o
are ocu sed on th e m an agem en t o bon e in ection s. Th ere
m ay also be patien ts wh o n eed vascu lar, u rological, or oth er
su rgical specialties or speci c in ju ries. Wh ile th e treatm en t
o an acu te early in ection sh ou ld be possible in all trau m a
u n its, m an agem en t o m ore com plex in ection s, ch ron ic
in ection s, an d in ected n on u n ion s sh ou ld be don e in spe-
cialist u n its with m u ltidisciplin ary team s [39, 40]. Th is approach
h as been sh ow n to im prove patien t ou tcom es [41, 42].
156
Occasion ally, em ergen cy treatm en t m ay be n eeded in pa-
tien ts w ith severe early on set in ection an d system ic sign s
o sepsis (ie, pyrexia, h ypoten sion , tach ycardia). In th is
situ ation , th ere is little tim e to per orm a u ll preoperative
w orku p, bu t as a m in im u m , patien ts sh ou ld be reh ydrated
an d h ave blood cu ltu res taken be ore adm in istration o
broad-spectru m in traven ou s an tibiotics. In itial su rgery is
aim ed at obtain in g tissu e or m icrobial cu ltu re an d drain in g
an y collection s o pu s. Th is u rgen t in terven tion can be li e
or lim b savin g. It is n ot appropriate to em bark on com plex
recon stru ction in a system ically u n w ell patien t. Wou n ds
can be le t open an d dressed or m an aged w ith a tem porary
n egative-pressu re w ou n d closu re device or a very sh ort
period [43 ]. De n itive su rgery, in clu din g w ou n d closu re,
can th en be per orm ed w h en th e patien ts gen eral con dition
im proves.
3 .1 Acu t e in fe ct io n
It sh ou ld be n oted th at early, acu te in ection a ter an open
ractu re or in tern al xation is u su ally cau sed by a viru len t
organ ism ( Ta b le 9.1-1 ), w h ich w ill produ ce rapid tissu e de-
stru ction , bon e loss, ailu re o xation , an d ractu re n on -
u n ion . Urgen t treatm en t is n eeded to salvage th e xation
an d preven t th ese sequ elae.
Th ere is n o place or n on operative treatm en t with an tibiotics
alon e. It is w idely accepted th at ractu res can h eal in th e
presen ce o in ection , providin g th ey are stable, h ave good
so t-tissu e cover an d h ave e ective an tim icrobial su ppres-
sion . Th e aim o su rgery is to redu ce th e bacterial load,
en su re ractu re stability, im prove so t-tissu e cover, an d
allow an tibiotic su ppressive th erapy to u n ion o th e ractu re.
All in ected ractu res presen tin g early sh ou ld h ave a su rgical
exploration o th e w ou n d w ith collection o deep sam ples
as described above. Abscesses are drain ed an d all dead tissu e
sh ou ld be rem oved, in clu din g n on viable ragm en ts o bon e.
Th ere sh ou ld be n o attem pt to keep large dead bon e rag-
m en ts to preserve stability, as th is w ill sim ply m ain tain
bacterial bio lm an d lead to an in ected n on u n ion . I in itial
bon y resection resu lts in a segm en tal or m ajor bon e
de ect, th is can be m an aged as or in ected n on u n ion
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Martin A McNally
(see ch apter 9.2 In ected n on u n ion ). I sm aller de ects are
created, th ese can be treated by secon dary bon e gra tin g
a ter a period o an tim icrobial th erapy.
A ter resection , broad-spectru m in traven ou s an tibiotics
sh ou ld be given , w h ich w ill cover th e ran ge o cau sative
organ ism s. In tw o in depen den t series, th e com bin ation o
a glycopeptide with an an tipseu dom on al agen t (van com ycin
an d m eropen em ) w as sh ow n to be th e m ost appropriate
em piric regim en [36, 44]. Th is com bin ation is given or a ew
days u n til m icrobial cu ltu res allow selection o targeted
th erapy.
An early in ection can o ten be treated w ith reten tion o th e
im plan t, bu t th is sh ou ld on ly be con sidered i th e im plan t
is stable an d it is possible to ach ieve good so t-tissu e cover
over it [20, 45, 46]. Th e decision to keep an in ected im plan t
is di cu lt. Retain ed in ected im plan ts w ill be coated in bio-
lm , w h ich w ill poten tially allow persisten ce o organ ism s
a ter debridem en t [47 ]. Th is problem m ay be on ly partly
addressed by th e u se o bio ilm -active an tibiotics a ter
su rgery [48].
Rem oval o th e im plan t w ill produ ce in stability an d altern a-
tive xation w ill be requ ired. In com plex ractu re pattern s
arou n d join ts, it m ay be very di cu lt to ach ieve stability
w ith ou t im plan t reten tion . In a series o 97 cases o deep
in ection ollow in g an an kle ractu re, it h as been sh ow n
th at early im plan t rem oval prior to ractu re u n ion is a poor
progn ostic in dicator w ith an in creased risk o perm an en t
com plication s [49].
Stu dies o treatm en t o early in ected ractu res w ith im plan t
reten tion su ggest th at abou t 70% o cases w ill proceed to
u n ion [45, 46, 49], bu t th ere is o ten persisten t in ection a ter
u n ion (2940% ), requ irin g u rth er su rgery an d later recu r-
ren ce is com m on . In on e stu dy, on ly 49% o patien ts
rem ain ed w ith an in ection - ree u n ion at 6 m on th s a ter
treatm en t [46].
Several stu dies h ave sh ow n th at h ost com orbidities su ch as
sm okin g, diabetes, an d poor so t tissu es a ter an open ractu re
are predictive o ailu re. In Ciern y-Mader Grou p B h osts,
in ected im plan ts sh ou ld be rem oved i th ere is a reason able
altern ative xation possible.
In tram edu llary n ailin g provides a load-sh arin g con stru ct
w ith relative ractu re stability. With early in ection , th e
stability is o ten com prom ised, particu larly w ith u n ream ed,
sm all diam eter n ails. Th ere is also th e problem o dead bon e
on th e in n er su r ace o th e diaph ysis ( Fig 9.1-15 ) an d th e dead
space in side a h ollow n ail, w h ich can act as a reservoir or
in ection [50 ]. Th is com bin ation m akes it less likely th at an
in ected ractu re treated w ith n ail reten tion w ill do w ell [51,
52 ]. It is th ere ore recom m en ded th at m ost in ected n ails
sh ou ld be rem oved. Th e can al sh ou ld be ream ed [53] an d
deep sam ples sen t or cu ltu re. Th e u se o th e ream er irrigator
aspirator (RIA) m ay be h elp u l in th is situ ation [5 4 ]. Th e
bon e can be stabilized by in sertion o a n ew n ail, an an tibi-
otic-loaded cem en t n ail, or by application o an extern al
xator. An experim en tal stu dy h as in dicated th at th ere m ay
be som e advan tage in u sin g a solid titan iu m n ail rath er th an
a h ollow steel n ail to preven t in ection recu rren ce [5 0 ].
Recen tly, an tibiotic-coated n ails h ave been reported in th e
treatm en t o in ected n on u n ion o th e em u r an d tibia [55]
w ith a 60% su ccess rate. Th eir e cacy in early in ected
ractu res is n ot kn ow n .
A ter debridem en t, th ere m ay be bon y de ects in th e cortex
or w ith in th e m edu llary can al. Su per cial de ects can be
lled w ith h ealth y so t tissu e bu t deep cavities are m ore
di cu lt. It is n ot recom m en ded to u se stan dard bon e gra ts
in acu te in ection . De ects m ay be lled w ith an tibiotic-
elu tin g m aterials, w h ich w ill redu ce th e bacterial load. Poly-
m eth ylm eth acrylate (PMMA) beads w ith gen tam icin h ave
been th e best stu died delivery system [2 5, 3 1, 3 3, 5 6], bu t
th ere is n ow a ran ge o bioabsorbable m aterials th at can
elu te very h igh levels o an tibiotic arou n d th e ractu re site
[5 7 , 5 8 ]. See ch apter 6 Local delivery o an tibiotics an d
an tiseptics or addition al in orm ation . Th ese m aterials
in clu de calciu m su lph ate an d calciu m su lph ate/ h ydroxy-
apatite com posites w h ich dissolve over a variable period,
n egatin g th e n eed or bead rem oval. How ever, n on e o th ese
m aterials h ave su cien t m ech an ical stren gth to su pport an
u n h ealed ractu re an d m u st be com bin ed w ith ixation
( Fig 9 .1-23 ).
157
 Se ct io n 2Spe cial
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9.1Infe ction
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fracture
Th e ou tcom e o treatm en t o an in ected ractu re is greatly
a ected by th e con dition o th e so t tissu es arou n d th e
ractu re. In th e em u r, proxim al tibia, an d h u m eru s, it is
u su ally possible to cover plates an d in ected ractu res w ith
adjacen t so t tissu es or tran sposed local m u scle f aps. In -
ected ractu res o th e olecran on , distal bu la, an d tibia are
o ten associated w ith m ajor open w ou n ds a ter debridem en t
an d w ill n eed ree m icrovascu lar tissu e tran s er to allow
adequ ate cover or h ealin g. Th e u se o m u scle f aps h as been
sh ow n to im prove vascu larization arou n d ractu res, deliver-
in g oxygen , h ost im m u n e cells, an d an tim icrobial agen ts.
Th ey are h igh ly resistan t to in ection an d aid elim in ation
o bacteria [25].
In th e past, it w as com m on to h ave serial debridem en ts w ith
open w ou n d treatm en t over several days or w eeks. Th is
approach resu lts in delay o w ou n d h ealin g an d does n ot
im prove ou tcom e [20] an d can lead to su perin ection . So t-
tissu e cover, in clu din g ree m u scle f ap tran s er, can sa ely
be per orm ed du rin g th e sam e operation as th e in itial de-
bridem en t. I , or practical reason s, it can n ot be ach ieved in
th is w ay, tem porary occlu sive dressin gs or a n egative-
pressu re w ou n d dressin g can be u sed or a sh ort period.
How ever, n egative-pressu re w ou n d th erapy sh ou ld n ot be
u sed as th e de n itive m an agem en t or th e so t tissu es in
a b
Fig 9.1-23a b This tibial fracture de ve lope d an e arly infe ction. It
was de bride d and de e p sam ple s take n which gre w Sta phylococcus
a ure us. The surge on re taine d the m e talwork as he be lie ve d it was
stable .
a The wounds we re lle d with ge ntam icin- lle d
polym e thylm e thacrylate be ads.
b Afte r 10 days the be ads we re re m ove d and a fre e m uscle ap
was use d to cove r the de fe ct. The patie nt continue d on oral
suppre ssive antibiotics.
158
in ected ractu res. Negative-pressu re wou n d spon ges rapidly
becom e colon ized w ith bacteria an d m ay in du ce secon dary
in ection an d prom ote an tibiotic resistan ce [43]. In gen eral,
de n itive w ou n d closu re sh ou ld be ach ieved w ith in 7 days
o debridem en t or as soon as possible.
E ective m an agem en t o su spected early in ection w ill o ten
allow reten tion o a stable im plan t an d cu ltu re-gu ided
an tim icrobial th erapy to ractu re u n ion . It is recom m en ded
th at or a rapidly diagn osed an d treated early in ection ,
an tibiotic th erapy sh ou ld be con tin u ed or 3 m on th s [59] or
u n til ractu re u n ion . On ce u n ion h as occu rred, th e im plan t
sh ou ld be rem oved an d an y rem ain in g dead bon e excised.
Th e resu ltin g bon e de ect sh ou ld be m an aged as or a
ch ron ic osteom yelitic cavity (see topic 3.2 o th is ch apter).
Du rin g an tibiotic su ppressive th erapy, th e patien t m u st be
care u lly an d regu larly review ed w ith x-rays an d w ou n d
in spection . Wou n d breakdow n , system ic u pset (eg, pyrexia,
tach ycardia, an orexia), in ability to tolerate an tim icrobials,
or deterioration on th e x-ray, all su ggest th at su ppressive
th erapy is n ot w orkin g an d u rth er in terven tion w ill be
requ ired. It is n ot appropriate to con tin u e to w atch a ractu re
w ith progressive bon e loss, in ected so t tissu es, or a sys-
tem ically ill patien t ( Fig 9 .1-24 ).
a b
Fig 9.1-24a b This fracture (as se e n in Fig 9.1-23 ) was followe d up
ove r 5 m onths. The patie nt re m aine d we ll and the wound was dry.
The patie nt was se e n on only two occasions with the se x-rays at 2
(a ) and 5 ( b ) m onths. The x-rays show progre ssive bone re sorption,
loose ning of the xation, and scre w bre akage , indicating a failure of
e arly m anagem e nt and active infe ction of the fracture . This re quire d
se gm e ntal re se ction and Ilizarov bone transport to se cure union.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Martin A McNally
3 .2 Ch ro n ic in fe ct io n
Ch ron ic in ection u su ally presen ts late in on e o tw o w ays.
First, an early in ection can be m issed or treated poorly w ith
an tibiotics, allow in g th e in ection to progress an d even tu -
ally presen t w ith a m u ch m ore developed pictu re. Th is w ill
n orm ally appear as a delayed presen tation w ith in 1012
w eeks o in ju ry an d w ith an u n h ealed ractu re. Secon dly,
low -viru len ce organ ism s can cau se su bclin ical in ection w ith
n o early clin ical sign s. In su ch a situ ation , th e patien t w ill
presen t w ith in dolen t pain or local sw ellin g bu t rarely w ith
stu lation or system ic ill h ealth . Laboratory in vestigation s
are n ot u su ally h elp u l. Late in ection s m ay becom e clear
w h en th e ractu re ails to u n ite an d th e xation ails.
Diagn ostic in vestigation s sh ou ld ocu s on establish in g i th e
ractu re is h ealed or n ot. Plain x-rays an d CT scan n in g are
th e m ost u se u l in th is. Occasion ally, it is n ecessary to screen
th e ractu re u n der im age in ten si cation w ith valgu s an d
varu s stress to con rm u n ion .
3 .2 .1 De la ye d p re se n ta tio n
In con trast to early in ection s, th e lon ger du ration o ch ron ic
in ection allow s late cases to develop exten sive m atu re
bio lm on im plan ts an d dead bon e su r aces. In ection can
spread in to adjacen t so t tissu es with su bperiosteal abscesses
an d sin u s tracks. In tram edu llary n ails acilitate spread alon g
th e m edu llary can al to lockin g screw sites. In retrograde
em oral n ails or in an tegrade tibial n ails, th e kn ee join t m ay
develop septic arth ritis. Metaph yseal plates can in ect th e
adjacen t join t. An y previou s su boptim al an tibiotic th erapy
m ay h ave also produ ced resistan t bacterial strain s. Th e
su ccess rate o treatm en t o late in ection s is depen den t on
th e du ration o th e in ection [23, 25].
Delay cau ses disu se osteopen ia in th e w h ole bon e an d local-
ized bon e lysis arou n d th e ractu re an d xation device. Th is
com bin ation m ean s th at ch ron ic in ection s w ill o ten h ave
u n stable ixation . In gen eral, ch ron ic in ection s w ith an
u n h ealed ractu re sh ou ld be treated w ith rem oval o th e
origin al xation im plan t. Replacem en t w ith n ew xation
w ill be n eeded i th e ractu re is n ot h ealed an d, in m ost
cases, th is w ill in volve con version to an extern al xator.
Wh ile th is m ay be in con ven ien t or th e patien t, it o ers th e
best ch an ce o in ection - ree u n ion with ou t revision su rgery
[40].
159
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9.1Infe ction
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fracture

In delayed cases, th ere is o ten m ore exten sive so t-tissu e
in volvem en t an d scarrin g w ith poor tissu e per u sion . Th is
is particu larly problem atic arou n d th e tibia a ter platin g.
Early assessm en t by a plastic su rgeon is advised as m an y
cases w ill n eed radical skin excision an d ree f ap cover.
Bon e excision sh ou ld also be radical to rem ove an y rem n an ts
o n ecrotic bon e an d bio lm an d to redu ce th e bacterial load
in th e w ou n d. Th is w ill likely produ ce sign i can t bon e de-
ects w h ich m u st be lled w ith livin g tissu e (m icrovascu lar
f aps) or an tibiotic carriers ( Fig 9.1-25 ).
Th e ch oice o replacem en t xation m ay be di cu lt. In som e
in ected ractu res (eg, proxim al h u m eru s, proxim al em u r,
pelvis) extern al xation is n ot alw ays possible an d so n ew
in tern al xation m ay be n eeded. How ever, th e u se o in -
tern al ixation in active in ection is associated w ith a
h igh er in ection recu rren ce rate an d h igh reoperation rate
[55, 40, 60].
Exch an ge n ailin g in ch ron ic in ection s h as been advocated
bu t th ere is n o con sen su s on its u se [6 1 ]. In a care u lly
selected grou p o tibial in ection s, exch an ge n ailin g allow ed
less th an h al th e ractu res to h eal w ith ou t u rth er in terven -
tion [6 2 ]. Th is con cern h as prom pted som e su rgeon s to
per orm staged n ailin g. In stage on e, th e in ected n ail is
rem oved an d th e can al is ream ed an d sam pled. A tem porary
an tibiotic-loaded PMMA n ail is in serted an d a ter 34 w eeks
th e PMMA n ail is exch an ged or an in terlockin g n ail [61, 63].
3 .2 .2 La te p re se n ta tio n
A ter several m on th s, an in ected ractu re w ill be eith er
h ealed w ith an on goin g in ection , or is u n likely to progress
to h ealin g w ith ou t in terven tion , ie, in ected n on u n ion . Th ere
is n o u rgen cy or treatm en t. It is m ore im portan t to u lly
assess th e patien t an d to correct an y gen eral m edical con di-
tion s prior to su rgery. Tim e is well spen t on sm okin g cessation ,
im provin g n u trition , atten tion to diabetes care, ration alizin g
dru g th erapies, an d im provin g vascu lar statu s [33, 39, 64]. I
th e patien t is system ically w ell, an tibiotic th erapy sh ou ld
be stopped at least 2 w eeks be ore su rgery to im prove th e
yield o bacteria in deep-tissu e sam ples [25, 36].

a b c
Fig 9.1-25a c This ope n tibial fracture occurre d afte r a m otorcycle accide nt. The
patie nt was re fe rre d to the Bone Infe ction Unit at the author's hospital 16 we e ks afte r
the injury with infe ction that had be e n pre se nt since the original injury.
a The re was m ajor skin bre akdown with e xpose d m e talwork.
b c The fracture xation was unstable , with loose fragm e nts of de ad bone and
poste rior involucrum/ callus.

160 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Martin A McNally

d e f g

h i j
Fig 9.1-25d j
d The patie nt was unwe ll and had be e n give n oral antibiotics for 7 we e ks without surge ry. At ope ration, the loose m e talwork was
re m ove d with se ve ral large fragm e nts of ne crotic cortical bone . The tibia was stabilize d with an Ilizarov xator and a fre e latissim us dorsi
muscle ap transfe rre d for skin cove r. The large bone de fe ct was lle d with 20 m L of a calcium sulphate/ hydroxyapatite bioabsorbable
com posite with ge ntam icin. De e p -tissue sam ple s gre w polym icrobial infe ction with Sta phylococcus a ure us, Kle bsie lla spe cie s and
Prote us spe cie s.
e At 9 we e ks, the biocom posite is re m ode lling and fracture he aling is progre ssing.
f g The xator was re m ove d at 13 we e ks (29 we e ks afte r injury) and the patie nt re maine d with an infe ction-fre e lim b with bone union
9 m onths late r.
h j The patie nt re gaine d e xce lle nt re turn of function in his fram e .

161
 Se ct io n 2Spe cial
situations
9.1Infe ction
after
fracture

La te p re se n ta tio n w ith a h e a le d fra ctu re
In ected ractu res m ay presen t a ter bon e h ealin g w ith
residu al in ection rom an early in ection . Occasion ally, a
w ell-h ealed, sterile ractu re w ill becom e in ected rom a
con tigu ou s or rem ote ocu s by direct seedin g or h em atog-
en ou s spread. Th is is u su ally w ith a h igh -viru len ce organ ism
an d w ill presen t like acu te osteom yelitis.
A ter rem oval o an in ected in tram edu llary n ail, th e can al
sh ou ld be ream ed to at least 14 m m greater th an th e diam -
eter o th e n ail bein g rem oved [61]. It h as been su ggested th at
th e em u r sh ou ld be ream ed to 17 m m (+/ - 1.5 m m ) an d th e
tibia to 15 m m (+/ - 1.5 m m ) [53]. However, care sh ou ld be
taken w ith n arrow bon es to avoid pen etration or ractu re or
bon y n ecrosis du e to th erm al in ju ry du rin g ream in g.

Patien ts u su ally com plain o pain , sw ellin g, an d system ic
sym ptom s prior to sin u s disch arge rom th e ractu re or
su rgical scars. Rarely, a patien t m ay presen t w ith a n ew
path ological ractu re th rou gh th e area o in ection a ter
xation rem oval.
Treatm en t em ploys th e prin ciples o m an agem en t or
ch ron ic osteom yelitis o an y etiology [20, 33, 39]. Th e im plan t
sh ou ld be rem oved an d deep sam ples are taken or m icro-
biology an d h istology. In th ese cases, th ere is alw ays at least
Ciern y-Mader type III bon e in volvem en t w ith cortical an d
m edu llary in ection . It is essen tial to per orm an adequ ate
bon e resection a ter im plan t rem oval. Un der plates, th ere
is typically a layer o dead cortical bon e an d th e screw h oles
w ill o ten con tain dead or in ected tissu e ( Fig 9.1-26 ).
Th e can al m u st be care u lly w ash ed o debris. To acilitate
th is, a cortical w in dow m ay be created distally. Th is can be
created arou n d th e area o th e lockin g screw s.
Recu rren ce o in ection a ter rem oval o an in tram edu llary
n ail is com m on . Th is is u su ally du e to in adequ ate bon e ex-
cision or ailu re to m an age th e m edu llary dead space. Wh en
in ection h as been presen t or a prolon ged period arou n d an
in tram edu llary n ail, it can produ ce dead bon e ou tside th e
reach o a cen tral ream er. Th ere m ay be periph eral dead
bon e ragm en ts at th e ractu re site, arou n d lockin g screw
h oles, in cortical bon e, an d in th e m etaph yseal region s
( Fig 9 .1-27 ). Th ese areas can on ly be resected by open in g
win dows over th e dead segm en ts. Su ch areas can be iden ti ed
by MRI or SPECT/ CT a ter rem oval o th e in tram edu llary n ail.

a b c
Fig 9.1-26a c This originally close d tibial fracture was succe ssfully tre ate d with inte rnal xation. The patie nt pre se nte d late with pain, swe lling
and e rythe m a.
a The plate was re m ove d and pus draine d from the wound.
b Unde r the plate the re is a surface of de ad bone and the e dge s of the fracture site are also de ad (com pare with Fig 9.1-13 and
Fig 9.1-14 ). The fracture has he ale d by surrounding callus.
c Afte r plate re m oval, the de ad cortical bone m ust be re m ove d and the scre w hole s ove rdrille d to pre ve nt re curre nce of the infe ction. The
distal bone de fe ct was m anage d with a bioabsorbable , ge ntam icin-loade d antibiotic carrie r. Afte r surge ry, de e p culture s gre w coagulase -
ne gative staphylococci, tre ate d with a short course of oral antibiotics.

162 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Martin A McNally
A ter im plan t rem oval an d bon e excision , th e resu ltin g bon e
de ect m u st be m an aged. I th ere is a sh allow de ect on th e
su r ace o th e bon e, th is can be lled w ith th e su rrou n din g
livin g tissu e. Deep, cavitary de ects sh ou ld n ot be le t u n lled
as th is predisposes to recu rren t in ection an d ractu re [57,
65, 66]. Medu llary de ects can be lled w ith an tibiotic-load-
ed PMMA beads or cu stom an tibiotic-loaded PMMA rods
[63] bu t both n eed to be rem oved w ith in 4 w eeks o im plan -
tation . Th e resu ltin g de ect m ay n eed secon d-stage bon e
gra tin g to avoid ractu re [67].
De ect llin g w ith absorbable calciu m su lph ate pellets h as
dem on strated good resu lts in large series bu t does n ot
prom ote reliable bon e orm ation [57, 66]. Bioactive glass h as
been u sed in in ected bon e de ects w ith en cou ragin g early
resu lts [68]. Th e u se o com posite m aterials w h ich deliver
an tibiotics an d poten tially prom ote bon e in grow th is an
in terestin g recen t developm en t [69 ]. Th is is im portan t as
re ractu re a ter treatm en t o ch ron ic in ection h as been
reported betw een 38% [57].
Extern al xation pin s m ay develop a ch aracteristic ch ron ic
in ection th at can persist a ter pin rem oval. Th e plain x-ray
will sh ow a rin g o dead bon e, ie, rin g sequ estru m ( Fig 9.1-28 ).
Th is m ay be n atu rally expelled rom th e bon e with resolu tion
o th e in ection bu t m ore o ten n eeds to be rem oved an d a
sh ort cou rse o an tibiotics given .
1
2
a b c a
Fig 9.1-27 a c This patie nt pre se nte d 7 m onths afte r re m oval of an
infe cte d intram e dullary nail with pe rsiste nt pain and sinus discharge
from the distal locking scre w scars.
a Magne tic re sonance imaging de m onstrate s the ce ntral high
signal in the m e dullary canal.
b The pre se nce of e ndoste al e rosion ( 1 ) in the distal fe m ur with
de ad bone around the locking scre w hole s ( 2 ).
c An intracortical absce ss at the old fracture site ( 3 ). The se are as
cannot be re se cte d with m e dullary re am ing alone .
La te p re se n ta tio n w ith n o n u n io n
Un h ealed ractu res presen tin g late a ter in ju ry (> 3 m on th s)
w ith establish ed in ection rem ain on e o th e m ost di cu lt
problem s in orth opedic su rgery. Close m u ltidisciplin ary
team w ork is n eeded w ith a w ide ran ge o su rgical skills an d
m icrobiological expertise to ach ieve good ou tcom es [25, 40,
41, 42]. See ch apter 9.2 In ected n on u n ion .
4 Co n clu s io n
E ective treatm en t o in ected ractu res requ ires an u n der-
stan din g o th e etiology an d path ogen esis o in ection .
Su rgeon s sh ou ld be aw are o th e presen ce o bio lm s an d
con sider th e an atom ical distribu tion o dead bon e arou n d
ractu res an d xation devices. Treatm en t protocols m u st be
delivered by m u ltidisciplin ary team s an d m u st in clu de th e
m ajor prin ciples described above. As a m in im u m , treatm en t
m u st in clu de optim ization o th e gen eral h ealth o patien ts,
deep tissu e sam plin g, adequ ate bon y excision , stabilization ,
dead space m an agem en t, so t-tissu e cover an d cu ltu re-
speci c an tim icrobial th erapy.
5 Ack n o w le d gm e n t s
I am grate u l to Geert Walen kam p, Peter Och sn er, an d th e
late George Ciern y III or developin g m an y o th e con cepts
described in th is ch apter an d w h ich h ave allow ed su ccess u l
treatm en t or m an y patien ts.
1
b
Fig 9.1-28 a b Afte r re m oval of an e xte rnal xator, this patie nt
had continue d discharge from a ce ntral diaphyse al pin site ove r
se ve ral we e ks. All of the othe r pin site s he ale d without infe ction.
a Plain x-ray shows a typical ring se que strum in the midtibia
with a ce ntral ring of de ad bone and surrounding bone
re sorption ( 1 ).
b The se que strum was drille d out and the de fe ct lle d with
an absorbable biocom posite with ge ntam icin to avoid
fracture or re curre nt infe ction.
163
 Se ct io n 2Spe cial
situations
9.1Infe ction
after
fracture
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xation o an k le ractu res. Injury. 2013
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50. Me lch e r GA, Ha u ke C, Me t zd o rf A, e t a l.
In ection a ter in tram edu llar y n ailin g:
an ex perim en tal in vestigation on
rabbits. Injury. 1996; 27 Su pp 3:SC23
26.
51. Ma k rid is KG, To s o u n id is T, Gia n n o u d is
PV. Man agem en t o in ection a ter
in tram edu llary n ailin g o lon g bon e
ractu res: treatm en t protocols an d
ou tcom es. Open Orthop J. 2013
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52. Al-Ma ya h i M, Be t z M, M lle r DA, e t a l.
Rem ission rate o im plan t-related
in ection s ollow in g revision su rgery
a ter ractu res. Intern Orthop. 2013
Nov;37(11):2253 2258.
53. Och s n e r PE, G s e le A, Bu e s s P. Th e
valu e o in tram edu llar y ream in g in th e
treatm en t o ch ron ic osteom yelitis o
lon g bon es. Arch Orthop Trauma Surg.
1990;109(6):341347.
54. Za la vra s CG, Sirk in M. Treatm en t o
lon g bon e in tram edu llar y in ection
u sin g th e RIA or rem oval o in ected
tissu e: in d ication s, m eth od an d clin ical
resu lts. Injury. 2010 Nov;41 Su ppl
2:S43 47.
55. Co n w a y J, Ma n s o u r J, Ko t ze K, e t a l.
An tibiotic cem en t-coated rods: an
e ective treatm en t or in ected lon g
bon es an d prosth etic join t n onu n ion s.
Bone Joint J. 2014
Oct;96-B(10):1349 1354.
56. Ha n s s e n AD. Local an tibiotic delivery
veh icles in the treatm en t o
m u scu loskeletal in ection . Clin Orthop
Relat Res. 2005 Au g;(437):9196.
57. Fe rgu s o n JY, Du d a re va M, Rile y ND, e t
a l. Th e u se o a biodegradable
an tibiotic-loaded calciu m su lph ate
carrier con tain in g tobram ycin or th e
treatm en t o ch ron ic osteom yelitis: a
series o 195 cases. Bone Joint J. 2014
Ju n ;96-B(6):829 836.
58. Za la vra s CG, Pa t za k is MJ, Ho lt o m P.
Local an tibiotic th erapy in th e
treatm en t o open ractu res an d
osteom yelitis. Clin Orthop Relat Res.
2004 Oct;(427):86 93.
59. Se n d i P, Zim m e rli W. An tim icrobial
treatm en t con cepts or orth opaed ic
device-related in ection . Clin Microbiol
In ect. 2012 Dec;18(12):1176 118 4.
60. Pra s a rn ML, Ah n J, Ach o r T, e t a l.
Man agem en t o in ected em oral
n onu n ion s w ith a sin gle-staged
protocol u tilizin g in tern al xation .
Injury. 20 09 Nov;4 0(11):1220 1225.
61. Brin ke r MR, OCo n n o r DP. Exch an ge
n ailin g o u n u n ited ractu res. J Bone
Joint Surg Am. 2007 Jan ; 89(1):177188.
62. Pe t ris o r B, An d e rs o n S, Co u rt-Bro w n
CM. In ection a ter ream ed
in tram edu llary n ailin g o th e tibia: a
case series review. J Orthop Trauma.
2005 Au g;19(7):4374 41.
63. Ma d a n a go p a l SG, Se ligs o n D, Ro b e rt s
CS. Th e an tibiotic cem en t n ail or
in ection a ter tibial n ailin g.
Orthopedics. 20 04 Ju l;27(7):709 712.
6 4. La zza rin i L, Ma d e r JT, Ca lh o u n JH.
Osteom yelitis in lon g bon es. J Bone
Joint Surg Am. 2004
Oct;86-A(10):2305 2318.
65. McKe e MD, Li-Bla n d EA, Wild LM, e t a l.
A prospective, ran dom ized clin ical trial
com parin g an an tibiotic-im pregn ated
bioabsorbable bon e su bstitu te w ith
stan dard an tibiotic-im pregn ated
cem en t beads in th e treatm en t o
ch ron ic osteom yelitis an d in ected
n onu n ion . J Orthop Trauma. 2010
Au g;24(8):483 490.
66. Ch a n g W, Co la n ge li M, Co la n ge li S, e t
a l. Adu lt osteom yelitis: debridem en t
versu s debridem en t plu s Osteoset T
pellets. Acta Orthop Bel. 2007
Apr;73(2):238 243.
67. McNa lly MA, Sm a ll JO, To gh i HG, e t a l.
Two stage m an agem en t o ch ron ic
osteom yelitis o th e lon g bon es. Th e
Bel ast Tech n iqu e. J Bone Joint Surg Br.
1993 May;75(3):375 380.
68. Ro m a n CL, Lo go lu s o N, Me a n i E, e t a l.
A com parative stu dy o th e u se o
bioactive glass S53P4 an d an tibiotic-
loaded calciu m su lph ate bon e
su bstitu tes in th e treatm en t o ch ron ic
osteom yelitis. Bone Joint J. 2014
Ju n ;96-B:845 850.
69. McNa lly MA, Fe rgu s o n JY, La u A e t a l.
Sin gle-stage treatm en t o ch ron ic
osteom yelitis w ith a n ew absorbable,
gen tam icin -loaded, calciu m su lph ate /
h ydroxyapatite biocom posite. A
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165
 Se ct io n 2Spe cial
situations
9.1Infe ction
after
fracture

166 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Johan Lammens, Pe te r E Ochsne r, Martin A McNally

9.2 In fe cte d n o n u n io n
Jo h an Lam m e n s, Pe te r E Och sn e r, Martin A McNally

1 Ba s ics Th e in ection m ay be acu te or ch ron ic. As a ru le, th e in ection s

An in ected n on u n ion is de n ed as a ractu re site w h ere th e
presen ce o in ection com prom ises h ealin g o th e ractu re.
Non u n ion can be said to h ave occu rred w h en ever n o u rth er
progression o ractu re h ealin g can be observed an d th e
ractu re w ill n ot h eal w ith ou t in terven tion . In con trast to
aseptic n on u n ion s [1], th ese criteria or in ected n on u n ion
can be m et m u ch earlier. In th e presen ce o gross in stabil-
ity, u lm in an t in ection or m ajor bon e loss, it can be assu m ed
th at n o h ealin g w ill progress even sh ortly a ter in ju ry.
are exogen ou s in origin . Hem atogen ou s in ection rom a
distan t sou rce is a rare cau se o n on u n ion . Prim ary con -
tam in ation o open w ou n ds, in su icien t debridem en t,
destru ctive operative procedu res, n egative-pressu re w ou n d
th erapy or m ore th an 7 days an d too m u ch delayed so t-
tissu e closu re o th e ractu re sites are th e m ost im portan t
actors to avor th e developm en t o in ection an d im paired
bon e h ealin g.

Th ere are m u ltiple actors con tribu tin g to th e developm en t Patient Bone Surgery

o an in ected n on u n ion ( Ta b le 9 .2 -1 ). Th e m ost im portan t Obesity Open fracture Inadequate stabilization

are type III open ractu res, exten sive local so t-tissu e dam - Smoking Fracture type Excessive osteosynthesis

age, severe com m in u tion o th e bon e, presen ce o devitalized Drug abuse Fracture site Misalignment
bon e, an d in itial su rgical m ism an agem en t ( Fig 9 .2 -1 ) [2, 3]. Steroid use Bone defect Prolonged negative-pressure
wound therapy
Vascular insufficiency Soft-tissue deficiency Additional soft-tissue damage
(approach, periosteal stripping)
Immunosuppression Infection
Metabolic disorders
Endocrinological disorders

Ta b le 9 .2 -1 Ove rvie w of factors with a pote ntial in ue nce on the

de ve lopm e nt and he aling of infe cte d nonunion.

a b c
Fig 9.2-1 a c A 55 -ye ar-old m an with his lowe r le g crushe d by a falling tre e .
a AP x-ray shows se ve re com m inution.
b At admission after 3 months the x-ray shows almost no periosteal re action sugge sting that the bone is de ad.
c On e xam ination, the re is a m ajor soft-tissue de fe ct with visible bone fragm e nts. The xation is unstable .

167
 Se ct io n 2Spe cial
situations
9.2Infe cte d
nonunion

Th e classi cation s or n on u n ion s w ith ou t in ection are o 1.1 Cla s s ifica t io n

lim ited valu e in th e evalu ation o in ected n on u n ion s [4].
Th ere m ay be sign s o a h yper- or atroph ic n on u n ion on
x-ray, bu t th e m ain in dicators or th e severity o an in -
ected n on u n ion are th e exten t o bon e n ecrosis, th e presen ce
o dem arcated sequ estra ( Fig 9.2-2 ) an d th e viru len ce o th e
in ection .
Periosteal n ew bon e orm ation alon g th e bon e ragm en ts is
an im portan t sign o vitality, w h ereas its absen ce a ter sev-
eral m on th s in dicates th at th e bon e is dead. It m ay presen t as
a loose ragm en t su rrou n ded by in ected tissu e (sequ estru m )
( Fig 9 .2 -3 ).
As in in ected ractu res (see topic 1.4 in ch apter 9.1 In ection
a ter ractu re) it is h elp u l to su bdivide in ected n on u n ion s
to better u n derstan d th e com pon en ts o each case an d to
plan treatm en t. Th e classi cation o Weber an d Cech [4 ],
divides all n on u n ion s (aseptic an d septic) in to tw o broad
grou ps: viable an d n on viable n on u n ion s. Types A, B, an d
C are th e viable n on u n ion s w ith livin g bon e presen t on
both sides o th e u n h ealed ractu re. Th is is u n com m on in
establish ed in ected n on u n ion s. Types D an d E are n on -
viable n on u n ion s w ith dead bon e at on e or both en ds o
th e ractu re site. Type E h ave separate dead ragm en ts in
th e n on u n ion . Types F an d G are also n on viable w ith bon e

a b c

Fig 9.2-2a c A 55 -ye ar-old m an injure d in a car accide nt. Fig 9 .2 -3 Infe cte d nonunion of
a Ope n se gm e ntal fe m oral fracture , type 32-C2 , with plate oste osynthe sis the tibia afte r intram e dullary nailing.
change d to e xte rnal xation afte r 9 m onths be cause of se ve re posttraumatic The distal fragm e nt is viable with
oste omye litis. pe rioste al ne w bone form ation on the
b c The patie nt die d afte r 1 ye ar and the fe m ur was e xam ine d at post m orte m . m e dial side . The ce ntral and proxim al
Pe rioste al ne w bone formation is se e n m ainly on the m e dial side with partial fragm e nts showe d no pe rioste al
re m ode ling of the ce ntral se gm e nt. The re is de m arcation of the late ral corte x re action. The normal oste ope nia of
with e xte nsive granulation tissue and no signs of re m ode ling or pe rioste al disuse is se e n in the distal fragm e nt
ne w bone form ation (arrows). Ade quate de bride m e nt at this tim e would have but is abse nt from the ce ntral and
re quire d re m oval of, at le ast, the late ral part of the ce ntral se gm e nt (arrows) proxim al re gions. The re is also
and all the granulation tissue . intraarticular m alposition of the im plant
in the ankle joint and axial de viation.

168 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Johan Lammens, Pe te r E Ochsne r, Martin A McNally
gaps. Fig 9 .2 -3 sh ow s a typical Weber an d Cech Type E
in ected n on u n ion w ith a cen tral, n on viable, loose ragm en t.
Th is classi cation is u se u l becau se it h igh ligh ts th e im por-
tan ce o iden ti yin g areas o dead bon e w h ich m u st be
rem oved i in ection is presen t.
Th ere are m an y actors w h ich con tribu te to th e developm en t
o an in ected n on u n ion an d also to th e di cu lty or ease
w ith w h ich it can be treated. Th e Non -Un ion Scorin g System
(NUSS) proposed by Calori et al [5] ( Ta b le 9 .2 -2 ) in clu des th e
essen tial gen eral an d local risk actors con tribu tin g to th e
path ogen esis o a n on u n ion an d allow s calcu lation o a total
n u m erical score or each case. In ection is seen as a sin gle
con tribu tin g actor in n on u n ion bu t is given in creased
w eigh tin g in th e score. Th is NUSS m ay h elp in plan n in g th e
th erapy bu t also allow s com parative an alyses o in ected
n on u n ion s [6]. A special ladder strategy is described con -
sistin g o an algorith m or th e ch oice o treatm en t based on
th e severity as expressed by poin ts rom 0 to 50. It is su g-
gested th at th e score be m u ltiplied by tw o an d th at patien ts
w ith a score rom 0 to 25 can be treated w ith sim ple m easu res,
patien ts in th e 2675 ran ge w ill requ ire m ore specialist
treatm en ts, an d th ose over 75 poin ts m igh t be con sidered
or am pu tation . How ever, th is score an d th e treatm en t rec-
om m en dation s h ave n ot been w ell validated in in ected
cases an d som e issu es are con ten tiou s. For exam ple, w h y
adequ ate stability an d an atom ical align m en t h ave a n egative
im pact on th e total score is n ot discu ssed in th e paper.
Th e site o th e in ected n on -u n ion h as a great im pact on
th e ch oice o th e treatm en t. Epiph yseal-m etaph seal n on -
u n ion s occu r in can cellou s bon e w ith less ten den cy to se-
qu estration . Th e con tact su r ace o th e tw o m ain ragm en ts
is relatively large. Diaph yseal n on -u n ion s ten d to resu lt in
m ore exten sive bon e n ecrosis an d sequ estration a ter m ajor
trau m a.
169
 Se ct io n 2Spe cial
situations
9.2Infe cte d
nonunion

Score Max. score

Bone
Quality Good 0
Moderate, eg, mildly osteoporotic 1
Poor, eg, severe porosis or bone loss 2
Very poor (necrotic, appears avascular or septic) 3 3
Primary injuryopen or closed fracture Closed 0
Open 1 grade 1
Open 23 Agrade 3
Open 3 BCgrade 5 5
Number of previous interventions on None 1
this bone to procure healing
<2 2
<4 3
>4 4 4
Invasiveness of previous interventions Minimally invasive: closed surgery, eg, screws, K-wires 0
Internal intramedullary (nailing) 1
Internal extramedullary 2
Any osteosynthesis which includes bone grafting 3 3
Adequacy of primary surgery Inadequate stability 0
Adequate stability 1 1
Weber and Cech group Hypertrophic 1
Oligotrophic 3 3
Atrophic 5 5
Bone alignment Nonanatomical 0
Anatomical 1 1
Bone defectgap 0.51 cm 2
13 cm 3
> 3 cm 5 5
So t tissues
Status Intact 0
Previous uneventful minor surgery, minor scarring 2
Previous treatment of soft-tissue defect, eg, skin loss, local flap cover, multiple incisions, compartment syndrome, old sinuses 3
Previous complex treatment of soft-tissue defect, eg, free flap 4
Poor vascularity: absence of distal pulses, poor capillary refill, venous insufficiency 5
Presence of actual skin lesion/defect, eg, ulcer, sinus, exposed bone or plate 6 6
Patient
ASAgrade 1 or 2 0
3 or 4 1 1
Diabetes No 0
Yes: well controlled (HbA1c < 10) 1
Yes: poorly controlled (HbA1c > 10) 2 2
Blood tests FBC: WCC > 12 1
ESR > 20 1
CRP > 20 1 3
Clinical infection status Clean 0
Previously infected or suspicion of infection 1
Septic 4 4
Drugs Steroids 1
NSAIDs 1 2
Smoking status No 0
Yes 5 5

Ta b le 9.2-2 Non-Union Scoring Syste m (NUSS) according to Calori e t al [5 ].

Abbre viations: ASA, Ame rican Socie ty of Ane sthe siologists; FBC, full blood count; WCC, white ce ll count; ESR, erythrocyte sedimentation rate;
CRP, C-reactive protein; NSAID, nonsteroidal antiin ammatory drug.

170 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Johan Lammens, Pe te r E Ochsne r, Martin A McNally
2 Clin ica l fin d in gs a n d im a gin g
Th e diagn osis o an in ected n on u n ion is requ en tly obviou s.
An acu te in ection or a h istory o local drain age com bin ed
w ith th e absen ce o ractu re con solidation con rm s th e in -
ected n on u n ion . How ever, som e h ypertroph ic pattern s m ay
be very sti w ith little ractu re m obility. Clin ical exam in a-
tion n din gs o in ected n on u n ion in clu de lim pin g, u se o
cru tch es or th e low er extrem ity du e to pain , an d im paired
m obility o th e n eigh borin g join ts. Occasion ally th ere w ill
be in term itten t stu la orm ation w ith drain age, bu t also
com plete n etworks o di eren t stu lae with in tercon n ection s
m ay be ou n d.
Laboratory tests rarely give u se u l in orm ation . Th e eryth -
rocyte sedim en tation rate, th e C-reactive protein , an d th e
wh ite blood cell cou n t are o ten n orm al or on ly m oderately
elevated.
Low -grade in ection s m ay be di icu lt to diagn ose (see
ch apter 7 Diagn ostics or u rth er in orm ation ). With ou t a
drain in g stu la, th e on ly sign m ay be a progressive oste-
olysis arou n d th e im plan ts. Th e treatin g su rgeon m u st be
su spiciou s o an y ractu re w h ich ails to h eal despite adequ ate
stabilization an d closed so t tissu es. I th ere w as a previou s
h istory o an open ractu re, a w ou n d w h ich w as slow to
h eal, or oth er m edical con dition s (eg, diabetes, sm okin g,
periph eral vascu lar disease), it sh ou ld be su spected th at
low -grade in ection is th e cau se o poor h ealin g an d ap-
propriate in vestigation s sh ou ld be in itiated.
Microbiological diagn osis sh ou ld be establish ed rom deep
tissu e sam ples on ly (see ch apter 9.1 In ection a ter ractu re).
Su per cial w ou n d or sin u s sw abs sh ou ld n ot be u sed as th ey
w ill cu ltu re skin com m en sals w h ich are n ot represen tative
o th e tru e in ectin g path ogen .
2 .1 Im a gin g p ro ce d u re s
Th e ollow in g im agin g procedu res are essen tial or th e eval-
u ation o a su spected in ected n on u n ion (see ch apter 7
Diagn ostics or addition al in orm ation ):
Stan dard x-rays are th e m ost im portan t basis or
diagn osis. In addition to ollow -u p exam in ation s,
recen t im ages in 4 view s (AP, lateral, an d in tern al an d
extern al obliqu e) are especially in orm ative. Th e local
con dition o th e n on u n ion is o particu lar in terest,
n am ely th e exten t o an existin g bon e de ect, th e
periosteal reaction deliverin g in orm ation on th e
viability o th e u n derlyin g bon e, residu al oreign
bodies (eg, m etal, cem en t beads), sequ estra in th e bon e
( Fig 9 .2 -5a , 9.2-12 b ) an d so t tissu es, etc. Repeated x-rays
are also su itable or m on itorin g th e progress o h ealin g.
Com pu ted tom ograph y, possibly com bin ed w ith a
con trast sin ogram is th e m ost sen sitive exam in ation
m eth od to dem on strate sequ estra, bu t exten sive
experien ce is n eeded to di eren tiate betw een m in or
bon e irregu larities ollow in g com plicated bon e h ealin g
an d areas o in ected bon e n ecrosis an d sequ estru m
orm ation . It is also h elp u l to iden ti y n on in tegrated
bon e su bstitu tes.
Th ree-ph ase an d an tigran u locyte scin tigraph y m ay
h elp to assess bon e viability an d to localize in ection . A
su pplem en tal SPECT/ CT provides better an atom ical
resolu tion . Nan ocolloid can be an altern ative [7].
Magn etic reson an ce im agin g clearly reveals zon es o
in f am m ation based on th e edem a provoked by th e
local in ection bu t does n ot alw ays reveal sequ estra. It
is best or so t-tissu e exten sion s o pu s arou n d th e
bon e an d can delin eate sin u s tracts w ell. It plays a
su bordin ate role in th erapeu tic decision m akin g.
Fistu lograph y is particu larly u se u l in th e operatin g
room . Th e stu la is in jected w ith a m ixtu re o m eth y-
len e blu e an d x-ray con trast agen t. Th is en ables th e
stu lae to be traced w ith th e im age in ten si er. Du rin g
th e operation th e blu e dye can be ollow ed du rin g
dissection . Th e blu e trace u su ally can be ollow ed u p to
th e bon e bu t n ot in side th e bon e itsel .
An giograph y is essen tial i th ere is an y dou bt abou t
com prom ised circu lation o th e lim b. A ter a prolon ged
period w ith ch ron ic in ection an d n on u n ion , th e blood
vessels can be di cu lt to palpate. An giograph y sh ou ld
be u sed to plan a vascu larized ree f ap i th e vessels
can n ot be iden ti ed on Doppler u ltrasou n d.
171
 Se ct io n 2Spe cial
situations
9.2Infe cte d
nonunion
2 .2 As s e s s m e n t o f t h e fu n ct io n a l s t a t u s
Treatm en t o an in ected n on u n ion m ay in volve poten tially
very elaborate recon stru ction s, w h ich m ay last rom a ew
m on th s to m ore th an on e year. Care u l evalu ation o th e
gen eral con dition s o th e lim b is m an datory be ore decidin g
on an y treatm en t m eth od. In decidin g betw een a recon stru c-
tion attem pt an d am pu tation th e ollow in g actors avor
lim b preservation :
Foot: in tact plan tar sen sation , n o or correctable pes
equ in u s, pain - ree an kle join t eith er m obile or xed at
righ t an gle
Kn ee: n o severe or pain u l osteoarth ritis, n o or
correctable m alposition (axis or rotation ), active,
pain - ree m obility
Upper lim b n on u n ion w ith a w ell- u n ction in g h an d
Patien t w h o is able an d determ in ed to com plete a
recon stru ctive program
3 Tre a t m e n t
An y treatm en t o an in ected n on u n ion starts w ith an ex-
ten sive debridem en t in clu din g h arvestin g o tissu e sam ples
or bacteriology an d h istology. Th e cu re o in ection is th e
basis or an y de n itive treatm en t o th e n on u n ion . In m e-
taph yseal n on u n ion s com pression alon e is m ostly su cien t
to ach ieve bridgin g. In diaph yseal in ected n on u n ion s a
h ypertroph ic n on u n ion site is rare. Frequ en tly an exten sive
resection o dead bon e is n ecessary to elim in ate in ection
ollow ed by a com plex recon stru ction o th e bon e. Exten sive
osteoplastic m easu res are th en n eeded to ach ieve u n ion
w ith restoration o th e n orm al len gth o th e lim b.
3 .1 Ap p ro a ch , e xp lo ra t io n a n d d e b rid e m e n t
Approach : I possible, ch oose an approach alon g an old scar,
allow in g good access to th e w h ole area to be debrided
( Fig 9 .2 -4 a b ). I you plan addition al approach es th in k o
even tu al n eeds or a decortication an d placem en t o a can -
cellou s bon e gra t or o a plastic su rgeon or con n ectin g ree
f aps to th e rem ain in g vessels.
Exploration : Each operation on an in ected n on u n ion m u st
aim to clari y th e con dition o th e bon e an d so t tissu es. Th e
exten t o in ection is determ in ed; su itable sites or tissu e
sam plin g are iden ti ed. Tissu e sam ples rom th e n eigh bor-
h ood o plates an d n ails are especially im portan t ( Fig 9 .2-4b ).
Th e sam ples are cu t in h al sen din g on e part or m icrobio-
logical stu dies an d th e oth er part or h istological exam in a-
tion . At least 36 sam ples sh ou ld be taken w ith separate
172
in stru m en ts or each sam ple to avoid cross-con tam in ation .
I m etal im plan ts or oreign m aterial are presen t, th ey can
be sen t or son ication to cu ltu re organ ism s rom bio lm on
th e m aterial. Em piric an tibiotic th erapy sh ou ld be given
eith er im m ediately a ter sam plin g or 10 m in u tes prior to
th e release o a tou rn iqu et.
Debridem en t: Th is step is m an datory in th e treatm en t o
every in ected n on u n ion . Th e orth opedic im plan ts an d dead
bon e in h ibitin g bridgin g o th e n on u n ion sh ou ld be rem oved.
A redu ction o th e n u m ber o bacteria avors th e e ective-
n ess o th e im m u n e system an d an tibiotics. To de n e th e
exten t o stu lae an d abscess cavities an d th e location o
sequ estra, a com bin ed in jection o a m ixtu re o m eth ylen e
blu e an d x-ray con trast agen t can be h elp u l ( Fig 9 .2 -4 b ).
Exten sion o th e abscess cavities is seen w ith th e im age
in ten si er an d dissection is acilitated. Im plan ts an d all or-
eign bodies in clu din g previou sly in serted m aterial su ch as
gen tam icin beads, rem n an ts o bon e su bstitu tes or allogra ts
are rem oved. Dead bon e an d sequ estra, as w ell as in ected
m em bran es alon g th e abscess cavities an d stu lae are re-
sected. Th e elim in ation o sequ estra is relatively easy. Th ey
can be recogn ized preoperatively w ith stan dard x-rays or
com pu ted tom ograph y an d are su rrou n ded by gran u lation
tissu e, scars, or pu s. Som etim es th ey are bu ried in n ew bon e
orm ation in th e m edu llary cavity or with in periph eral callu s.
It can be di cu lt to decide th e correct exten t o bon e exci-
sion . A clear dem arcation betw een viable an d n on viable
bon e is n ot alw ays obviou s. It is a com m on error eith er n ot
to rem ove all th e dead bon e or to be too aggressive in th e
resection o vital bon e. In preoperative x-rays, n ecrotic bon e
m ay appear den se w ith clear cu t m argin s ( Fig 9.2-1 , Fig 9 .2 -2 ).
Bon e u n der rem odelin g becom es m etabolically active an d
appears osteopen ic on x-ray an d is covered w ith a n ew peri-
osteal bon e layer ( Fig 9 .2 -2 , Fig 9 .2 -3 ).
A sim ple an d accu rate w ay to dem on strate vitality is th e
in traoperative evalu ation o th e bleedin g o th e bon e. Bleed-
in g poin ts can be observed a ter rem oval o th e gran u lation
tissu e. A ch isel can be u sed to rem ove a th in layer o bon e
to detect sm all pu n ctate bleedin g poin ts, kn ow n as th e
paprika sign ( Fig 9.2-4c) [8]. Usin g a ch isel allows assessm en t
o th e bon e qu ality. Dead bon e is o ten brittle. Debridem en t
can be don e w ith a tou rn iqu et in f ated an d poin t bleedin g
w ill be seen in vital bon e w ith ou t releasin g it. At th e en d o
th e bon e resection , th e tou rn iqu et is rem oved an d th e re-
m ain in g bon e observed or bleedin g. O ten , exten sive m ed-
u llary bleedin g w ill obscu re th e vision bu t i an y area does
n ot bleed well, u rth er resection is n eeded. A ter debridem en t,
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Johan Lammens, Pe te r E Ochsne r, Martin A McNally

th e su rgical site sh ou ld be copiou sly irrigated w ith a salin e 3 .2 St a b iliza t io n

solu tion to redu ce th e bacterial load. Th e created de ect can
be le t open or tem porarily lled w ith a an tibiotic loaded
cem en t spacer.
Staged debridem en t: Usu ally, all rem oval o in ected bon e
can be ach ieved in on e stage an d th e operation can th en
proceed to recon stru ction . In situ ation s w ith exten sive bon e
n ecrosis or w ith a system ically u n w ell patien t, it m ay be
better to w ait or at least on e w eek betw een th e debridem en t
an d th e bon e an d so t-tissu e recon stru ction . Th is open s th e
possibility or a secon d-look debridem en t be ore th e recon -
stru ctive m easu res. At th e sam e tim e on e can begin w ith
th e de n itive an tibiotic th erapy accordin g to th e su sceptibil-
ity testin g o th e bacteria. Som e su rgeon s advocate repeated
su rgical debridem en t in seriou s cases bu t th is in creases th e
risk o su perin ection an d is rarely n eeded i a care u l
debridem en t is per orm ed at th e rst operation .
Ach ievin g stability a ter bon e resection is on e o th e m ost
im portan t com pon en ts o treatm en t o an in ected n on u n ion .
Stability allow s so t-tissu e h ealin g, bon e bridgin g, an d n eo-
an giogen esis w ith delivery o an tibiotics in to th e ractu re
site. Un stable bon es w ill h ave a h igh risk o recu rren t in ec-
tion an d persisten t n on u n ion .
3 .2 .1 Te m p o ra ry sta b iliza tio n
As a ru le, an in ected n on u n ion becom es m ore u n stable
a ter debridem en t, su ch th at stabilization is n ecessary. Gen -
erally, stabilization is per orm ed w ith an extern al xator.
Th is allow s bridgin g th e site o in ection w ith ou t tou ch in g
th e in ected ocu s an d m in im izin g th e ch an ce o rein ection .
Occasion ally, in ected n on u n ion s can be excised an d le t
w ith a segm en tal de ect. Th is m ay be appropriate in m id-
bu lar n on u n ion s an d in ected n on u n ion s o th e m id oot,
or m iddle m etatarsals.

a b

c d
Fig 9.2-4a d A 36 -ye ar-old m an.
a Fistula 6 m onths afte r lowe r le g oste osynthe sis, lle d with m e thyle ne blue be fore de bride m e nt.
b The granulation tissue around the plate has be e n staine d blue .
c Afte r de bride m e nt.
d Wound he aling afte r a local transposition ap, the de nude d poste rior are a be ing cove re d with a m e sh graft. The nonunion was stabilize d
with an e xte rnal xator.

173
 Se ct io n 2Spe cial
situations
9.2Infe cte d
nonunion
3 .2 .2 Fin a l s ta b iliza tio n
On ce th e local in ection is eradicated, prolon ged stabilization
m u st be m ain tain ed u n til th e n on u n ion site is bridged w ith
callu s. Th is can be a tim e-con su m in g a air, lastin g m an y
m on th s.
3 .2 .3 Exte rn a l fixa tio n
De n itive stabilization w ith an extern al xation rem ain s
th e treatm en t o ch oice in m ost cen ters. I th ere is to be
plastic su rgical recon stru ction , th e placem en t o th e xator
sh ou ld be discu ssed w ith th e plastic su rgeon prior to op-
eration . A u n ilateral xator ( Fig 9 .2 -4 d ) is less bu lky th an a
rin g xator an d m ay give better access or plastic su rgery.
A rin g xator accordin g to Ilizarov allow s su ccessive an gu -
lar correction s du rin g th e application , eg, th e correction o
a pes equ in u s. It provides excellen t an gu lar an d rotation al
stability an d allows early weigh t bearin g. Th e Ilizarov m eth od
o distraction osteogen esis is an essen tial tech n iqu e in th e
m an agem en t o in ected n on u n ion s.
3 .2 .4 In te rn a l fixa tio n
To com bin e early w eigh t bearin g w ith m in im al in con ve-
n ien ce or th e patien t, su rgeon s h ave con sidered in tern al
xation a ter resection o in ected n on u n ion s. Th is can be
per orm ed acu tely in th e sam e operation as th e debridem en t
or as a secon d stage a ter a period o extern al xation an d
an tibiotic th erapy.
174
Klem m tested th e u se o in terlockin g n ails a ter a radical
debridem en t, m ain ly local an tibiotic treatm en t an d extern al
xation [9]. He reported u n ion in 89% o em oral in ected
n on u n ion s bu t in on ly 62% o tibias. He con clu ded th at th e
m eth od w as n ot as sa e as extern al xation [9]. Later papers
com pared Ilizarov xation alon e w ith a xator exch an ged
to an in terlockin g n ail as a secon dary procedu re. Both grou ps
h ad com parable resu lts bu t th e patien ts w ith a ch an ge to
an in tram edu llary (IM) n ail experien ced ew er restriction s
[10]. Early con version to IM n ailin g m ay be m ore cost-e ec-
tive th an com pletin g th e treatm en t with an extern al device,
bu t risks or rein ection sh ou ld n ot be u n derestim ated [11].
A 27% risk or rein terven tion du e to rem ain in g problem s
o n on u n ion or recu rren ce o in ection is reported. Th is m ay
be con sidered as acceptable in view o th e com plex problem
an d th e lesser m orbidity com pared to extern al xation de-
vices [12 ]. Th e presen ce o a n ail a ter su ccess u l eradication
an d bon e u n ion w ill redu ce th e risk o re ractu re, bu t m ost
cen ters w ou ld recom m en d n ail rem oval to redu ce in ection
recu rren ce risk. More recen tly, IM n ails coated w ith an ti-
biotic-loaded polym eth ylm eth acrylate (PMMA) cem en t h ave
been in serted a ter radical debridem en t an d n orm alization
o th e seru m param eters or in ection (eryth rocyte sedim en -
tation rate, C-reactive protein , an d w h ite blood cell cou n t)
[13]. Th ese m ay o er som e advan tages bu t th ere is still a
su bstan tial risk o recu rren ce o in ection (2540% ) an d th e
n eed or u rth er su rgery.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Johan Lammens, Pe te r E Ochsne r, Martin A McNally
3 .3 Os t e o p la s t ic m e a s u re s
3 .3 .1 De co rtica tio n a n d ca n ce llo u s a u to gra ft
De co rtica tio n
Th e best place to pu t au togen ou s bon e gra t is in a w ell-
vascu larized area. Th is is th e case w h ere th ere is visible n ew
su bperiosteal bon e orm ation . Li tin g th is bon e togeth er
w ith th e periosteu m an d th e adjacen t m u scles w ith a cu rved
ch isel creates a pocket arou n d th e n on u n ion lin ed on both
sides by vital bon e lam ellae. Th is gap is lled w ith can cellou s
au togra t [4] w h ich u n dergoes qu ick rem odelin g in addition
creatin g n ew bon e.
Au to ge n o u s b o n e gra ft
Fresh au togen ou s can cellou s bon e gra t brin gs livin g osteo-
gen ic osteoblasts an d osteoin du ctive bon e m atrix to th e
n on u n ion site. It stim u lates th e en viron m en t to create n ew
bon e. A n etw ork o w oven bon e w ill develop w ith in abou t
6 w eeks lin kin g th e tw o sides o th e n on u n ion . In th e
presen ce o adequ ate stability rem odelin g o th is im m atu re
w oven bon e can begin . Can cellou s au togra t is th e ideal
m aterial to add to n on u n ion sites w ith sm all bon e de ects
i debridem en t o dead in ected bon e h as been su ccess u l.
Du e to th e lim ited qu an tity o can cellou s bon e available or
recon stru ction , segm en tal de ects are lim ited to a len gth o
abou t 34 cm . Beyon d th is lim it oth er strategies sh ou ld be
con sidered. Can cellou s au togra t is still con sidered as th e
gold stan dard or prom otin g u n ion an d llin g sm aller de ects
[14].
Ha rve s tin g o f ca n ce llo u s a u to gra ft
Can cellou s bon e gra t can m ain ly be extracted rom th e
posterior an d an terior iliac crests. For sm aller qu an tities,
th e proxim al tibia an d em u r, th e distal tibia, an d th e distal
radiu s can be con sidered. Milled cortical bon e can be h ar-
vested in th e m edu llary can al o th e em u r. Pre erably th e
su rgeon sh ou ld extract th e bon e gra t rom th e sam e side
w h ere th ere is th e in ected n on u n ion to repair:
Posterior iliac crest, ou ter side: Th is is a good sou rce or
can cellou s au togra t. Place th e patien t in th e lateral
decu bitu s position an d drape th e receivin g leg at th e
sam e tim e as th e iliac crest. Use an in cision alon g th e
iliac crest or an obliqu e on e rom cran ial m edial to
distal lateral avoidin g trau m a to th e clu n eal n erves an d
th e sciatic n erve. Prepare th e ou tside o th e iliu m
placed over th e sacroiliac join t. A cortical w in dow is
open ed rom th e iliac crest in distal direction or abou t
5 x 5 cm . Th e rem oved cortical section can be
ragm en ted in sm all pieces. Un dern eath you can
h arvest a great qu an tity o can cellou s bon e u sin g
cu rettes, cu rved bon e gou ges, an d ch isels. Cu t th e bon e
pieces to th e size o a pea an d store th em in a con tain er
covered w ith a m oist gau ze. Hem ostasis is ach ieved by
placin g a collagen spon ge. To avoid large blood loss,
eith er do n ot drain th e cavity or u se a drain w ith ou t
vacu u m . In som e in dication s th e patien t can rem ain
or th e w h ole in terven tion in a pron e position [15].
An terior iliac crest, in n er side: Th e in terven tion is
possible in su pin e position bu t th e am ou n t o gra ts
you are able to w ith draw is m ore lim ited. Wh en doin g
th e approach , take care o th e lateral em oral cu tan eou s
n erve. As w ith th e posterior approach , bon e gra t
h arvest m ay be ollow ed by sw ellin g, pain , h em atom a,
blood loss, an d even in ection [16].
Fem u r: Th e ream er irrigator aspirator (RIA) m eth od is
a n ovel tech n iqu e to obtain large am ou n ts o au togen ou s
gra t an d h arvest bon e rom th e in n er cortex o th e
em u r or tibia [17]. Large qu an tities o good qu ality
bon e gra t m ay be obtain ed w ith proven cell viability
equ al to iliac crest gra t [18]. As orth opedic an d trau m a
su rgeon s are am iliar w ith th e ream in g o ractu red
bon es, it provides a am iliar an d sim ple tech n iqu e.
How ever, du e to th e di eren t equ ipm en t an d pu rpose
o th is ream in g procedu re atten tion sh ou ld be paid to
avoid u n w an ted com plication s, in clu din g ractu re [19,
20]. Th e ream er irrigator aspirator is passed dow n th e
m edu llary can al on ly on ce in a pu lsatile w ay, u sin g a
ream er o a size 14 m m larger th an th e n arrow est
portion o th e m edu llary can al. Th e sm allest available
diam eter is 12 m m , th e largest 16.5 m m . A m edu llary
can al with a diam eter less th an 10 m m or an excessively
th in cortex sh ou ld be con sidered u n su itable as don or
sites. Eccen tric ream in g sh ou ld be avoided as th e sh arp
ron t an d lateral cu ttin g f u te o th e ream er cou ld
w eaken or per orate th e cortex leadin g to iatrogen ic
ractu res. Becau se sim u ltan eou s irrigation an d aspiration
is per orm ed du rin g th e ream in g, h igh strain on th e
ream er sh ou ld be avoided to preven t blockage o th e
su ction device. Con tin u ou s aspiration can m ask
poten tial blood loss w h ich sh ou ld be an ticipated. With
a correct application th e tech n iqu e is sa e w ith a
reported m orbidity less th an 2% [21 ]. Th e tech n iqu e is
recom m en ded or m ore exten sive de ects an d o ten
com bin ed w ith a pretreatm en t o th e de ect w ith th e
Masqu elet tech n iqu e as described in topic 3.3.4 o th is
ch apter [22].
175
 Se ct io n 2Spe cial
situations
9.2Infe cte d
nonunion

Pla ce m e n t o f th e gra ft sh ou ld exten d at least 2 cm beyon d th e lim it o th e

Approach : Th e recipien t site is exposed. Th e brotic
tissu e betw een th e m ain ragm en ts is care u lly resected
bu t th e periosteu m is preserved as m u ch as possible.
Th e bon e en ds are exposed an d addition ally debrided i
th ere are an y n on viable areas.
Wh ere to arran ge th e gra t ( Fig 9 .2 -5 ): Th e gra t sh ou ld
n ever be placed ou tside th e periosteu m w h ere it
can n ot u n ite w ith th e u n derlyin g bon e. Th ere ore th e
best preparation or gra tin g is a decortication , allow in g
con tact w ith h ealth y bon e u n der periosteu m . Th e gra t
de ect or th e n on u n ion . Most can cellou s gra t is packed
u n der th e decorticated lam ellae. Fragm en ts are also
packed arou n d th e proxim al an d distal ragm en ts an d
in betw een th e bon e en ds in de ect n on u n ion s. A ter
placem en t, th e skin over th e gra tin g site m u st be
closed. I n ecessary, th is m ay requ ire a plastic su rgical
procedu re w ith a local or ree f ap. Skin closu re is
easier in th e low er leg i th e gra t is placed on th e
dorsolateral aspect o th e tibia or betw een th e tibia an d
th e bu la w h ere you m ay create a bon y bridge.

a b c
Fig 9.2-5a c X-rays of the sam e patie nt as shown in Fig 9 .2-4 .
a Pre ope rative condition 5 m onths afte r oste osynthe sis (se e Fig 9 .2 -4 a ). The re are visible se que stra in the nonunion are a.
b Bridging autoge nous cance llous bone graft (arrow), e xte rnal xation for 3 m onths.
c Te n ye ars afte r re vision: no re curre nce , no oste oarthritis.

176 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Johan Lammens, Pe te r E Ochsne r, Martin A McNally

Pa p in e a u te ch n iq u e
Open can cellou s bon e gra tin g (Papin eau tech n iqu e), leav-
in g th e gra t exposed ben eath a n on adh eren t dressin g, is an
old tech n iqu e or recon stru ctin g n on u n ion s w ith lim ited
de ects [2 3 ]. A ter debridem en t, th e open w ou n d is pro-
tected rom su perin ection by an tiseptic ban dages, eg, soaked
w ith polyh exan ide. As soon as th e bon e de ect is covered
w ith clean gran u lation tissu e ( Fig 9.2-6a ), th e cavity is lled
w ith a su rplu s o can cellou s au togra t as a secon d step
( Fig 9 .2 -6 b ). Wou n d care is con tin u ed w ith m oist an tiseptic
dressin gs. Local su perin ection is requ en t. Su per icial
can cellou s bon e pieces w ill o ten ail to in tegrate an d m u st
be rem oved. As soon as th e w h ole su r ace o th e lled de ect
is covered w ith gran u lation tissu e, a split-skin gra t can be
placed [24, 25]. As a m odi cation , n egative-pressu re w ou n d
th erapy h as been u sed on top o th e gra t [2 6 ]. Papin eau
tech n iqu e is sim ple an d can be per orm ed w ith lim ited
resou rces, bu t it is tim e-con su m in g. Usu ally th e rem ain in g
scar is u n stable an d h as a ten den cy to open at in tervals w ith
recu rren t in ection ( Fig 9 .2 -6d ).
3 .3 .2 Allo gra ft
Allogra t is n ot a good option to overcom e bon e de ects in
th e presen ce o active in ection . A ter a sh ort in itial period
o osteoin du ction th e allogra t is su bject to an im m u n o-
logical an tibody reaction destroyin g th e positive in itial e ect.
Mixin g allogra t w ith can cellou s au togra t is con train di-
cated, o ten leadin g to th e destru ction o th e positive e ect
o th e au togra t ( Fig 9 .2 -12c , Fig 9.2-13 ).
3 .3 .3 Bo n e m o rp h o ge n e tic p ro te in s a n d o th e r su b s ta n ce s
to re p la ce b o n e
Th e u se o bon e-in du cin g m olecu les h as clin ically been lim -
ited to bon e m orph ogen etic protein (BMP)-2 an d BMP-7.
Both h ave been an alyzed in m u lticen ter stu dies; on e or
open ractu res an d on e or n on u n ion s.

a b

c d
Fig 9.2-6a d A 52-ye ar-old m an. Papine au te chnique of ope n cance llous autograft.
a Ope n wound with granulation tissue 3 we e ks afte r de bride m e nt, re ady for grafting.
b The de fe ct is ove r- lle d with m orse lize d cance llous autograft.
c The wound is cove re d with scar tissue afte r 4 m onths.
d Six ye ars late r, the patie nt had inte rm itte nt wound bre akdown in the unstable scar.

177
 Se ct io n 2Spe cial
situations
9.2Infe cte d
nonunion
Th e statistical an alysis sh ow s a sligh t to m oderate ben e cial
e ect o th e application [27, 28]. Bon e m orph ogen etic protein
recru its an d activates m esen ch ym al stem cells an d directs
th em tow ards th e osteogen ic lin eage [29] bu t its activity is
very sh ort-lived (u p to 24 h ou rs). Th e costs o BMP are h igh
an d th is lim its its u se [30]. In th e m etaph yseal area an d in
n orm otroph ic or h ypertroph ic diaph yseal n on u n ion th ere
is n o n eed or BMP. To be e ective in atroph ic diaph yseal
n on u n ion s an d in de ect pseu darth roses, BMP h as to be
com bin ed w ith can cellou s au togra t or cu ltivated m esen -
ch ym al stem cells in com bin ation w ith a sca old su ch as
tricalciu m ph osph ate [31]. Th ere are con cern s th at th e u se
o BMP in su praph ysiological doses as advocated by th e
m an u actu rer m ay provoke tu m ors [32].
Th e u se o an y BMP in in ected n on u n ion h as n ot been
evalu ated. It m ay be appropriate to con sider BMP im plan ta-
tion in patien ts w h o h ave a poor biological respon se (eg,
steroid u se, previou s radioth erapy to th e lim b, con n ective
tissu e disorder) or bon e h ealin g bu t th is requ ires u rth er
stu dy. Gen erally, it sh ou ld be u sed on ly du rin g a secon d-stage
recon stru ction a ter in ection h as been eradicated.
3 .3 .4 Th e in d u ce d m e m b ra n e p rin cip le
In in ected n on u n ion s th e su rrou n din g so t tissu es in clu din g
periosteu m h ave o ten been destroyed to a large exten t.
Masqu elet described a m eth od to create a n ew en viron m en t
in th e de ect area avorable to bon e recon stru ction [33]. A ter
th orou gh debridem en t, a PMMA spacer con tain in g an tibiot-
ics e ective again st th e path ogen ic bacteria is prepared an d
in serted in to th e bon e de ect ju st be ore h arden in g, th ereby
a b
Fig 9.2-7a c Induce d m e m brane principle according to Masque le t.
a b Place m e nt of ce m e nt in the de fe ct afte r de bride m e nt.
c Re m oval of the ce m e nt afte r 6 we e ks shows that a thick m e m brane is form e d.
178
sligh tly drapin g th e cem en t arou n d th e bon y edges ( Fig 9.2-
7a b ). Th e cem en t is care u lly covered by closin g th e su b-
cu tan eou s tissu e ollow ed by skin su tu res. Over tim e, th e
PMMA block becom es covered by a brovascu lar m em bran e.
A ter 48 w eeks, th e spacer is rem oved. Th e in du ced m em -
bran e arou n d th e cem en t can be seen to be vascu larized
w ith n ew blood vessel orm ation ( Fig 9.2-7 c ). Th e presen ce
o bon e precu rsor cells an d th e produ ction o bon e-in du cin g
grow th actors h ave been dem on strated [3 4 ]. Th e space
w ith in th is m em bran e is n ow packed w ith can cellou s au -
togra t. To gu aran tee stability, an extern al xator is appro-
priate, alth ou gh th e u se o n ails h as also been described [35].
Th e con solidation or de ects o arou n d 5 cm in len gth w ill
last 1 year or m ore [36]. Loss o stability or gen eral m edical
con dition s can im pair con solidation in m an y cases o large
de ects in th e low er lim b.
3 .3 .5 Th e Iliza ro v m e th o d
Ilizarov developed a system or th e stabilization o bon e
ragm en ts, or correction o de orm ity, an d bon e de ect llin g,
w h ile allow in g join t m otion an d reh abilitation . He described
in detail th e com bin ation o callu s distraction an d segm en tal
tran sportation [37]. Th e m ain advan tage o th is system is th e
regen eration o a segm en t o n ew au togen ou s bon e on th e
spot, ie, in th e diseased lim b itsel w ith ou t th e n eed o a
don or site [38]. Th e resu ltin g regen erated bon e h as adequ ate
diam eter or th e segm en t to be replaced an d h as m ech an ical
stren gth su perior to th at resu ltin g rom can cellou s au togra ts
an d ree vascu larized bon e gra ts. O all th e available m eth ods,
Ilizarov tech n iqu es rem ain th e m ost reliable in ach ievin g
in ection - ree u n ion ( Fig 9.2-8 ).
c
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Johan Lammens, Pe te r E Ochsne r, Martin A McNally

Depen din g on th e exten t o sh orten in g o th e lim b or len gth
o bon e de ect, th ere are ou r di eren t w ays o treatm en t,
as de n ed in th e gu idelin es o th e Fren ch Society o Orth o-
paedic Su rgery an d Trau m atology (SOFCOT) [39]:
Un i ocal com pression :
Resection an d com pression alon e. In case o m in im al
sh orten in g a ter segm en tal resection , th e site can be
acu tely com pressed, acceptin g th e sh orten in g. Th e
extern al xator h olds th e redu ction an d allow s u rth er
gradu al com pression , eg, 0.25 m m tw ice a day.
Un i ocal com pression -distraction :
Resection , acu te sh orten in g w ith com pression , an d
secon dary distraction (relen gth en in g) at th e site o th e
resected n on u n ion . Th e sh orten in g sh ou ld n ot exceed
3 cm . Th e resected n on u n ion is com pressed du rin g 2 or
3 weeks a ter wh ich a distraction is in itiated at 0.75 or 1
m m per day to restore th e leg len gth .
Bi ocal com pression -distraction :
Resection , acu te sh orten in g w ith com pression o th e
resection site, an d secon dary distraction th rou gh a
corticotom y at a distan t site. Th e sh orten in g sh ou ld n ot
exceed 36 cm . Th e corticotom y is distracted 0.75 m m
or 1 m m per day begin n in g a ter an in terval o 710
days or secon dary len gth en in g to restore n orm al leg
len gth .
Bi ocal bon e tran sport:
Resection w ith ou t sh orten in g, distan t corticotom y, an d
secon dary segm en tal tran sportation u n til com pression
in th e dockin g (resection ) site. Use u l or de ects
greater th an 3 cm , u p to 15 cm or m ore ( Fig 9.2-8 ). Th e
speed o th e segm en tal tran sportation is 0.75 m m or 1
m m per day. I addition al len gth en in g is n eeded in th e
tibia, a bu lar osteotom y m ay be n ecessary.

a b c

d e f g h
Fig 9 .2 -8 a h A 39 -ye ar-old man suffe re d an ope n tibial fracture .
a b Patie nt was tre ate d with e xte rnal xation and a fre e m uscle ap and local polym e thylm e thacrylate antibiotic be ads.
c Patie nt de ve lope d an e arly infe ction which was tre ate d by a 5 cm se gm e ntal re se ction and Ilizarov bone transport.
d e The lim b was initially shorte ne d by 2.5 cm to allow docking to occur m ore quickly.
f Afte r docking, the le ngthe ning was continue d to full le g le ngth.
gh Final outcom e at 14 m onths showe d an infe ction-fre e lim b with good alignm e nt and good function. Bone transport proce e de d unde r
the m uscle ap without dif culty.

179
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situations
9.2Infe cte d
nonunion
Th e ch oice betw een solu tion 3 an d 4 depen ds on several
actors. Sh orten in g in th e low er leg o m ore th an 34 cm is
tech n ically dem an din g an d n ot w ith ou t risk. Th ere are prob-
lem s w ith so t tissu es in clu din g vascu lar risks. Care u l ob-
servation o th e blood su pply to th e h an d or oot is n eeded
du rin g acu te sh orten in g o m ore th an 3 cm . I isch em ia is
seen , th e lim b can n ot be acu tely sh orten ed to bon e con tact
an d a bon e tran sport w ill be n eeded.
Early bon e con tact in th e segm en tal resection w ith acu te
com pression w ill u su ally im prove regen erate orm ation an d
m atu ration an d allow sh orter xator tim es. How ever, in th e
low er leg a resection o th e bu la w ill be n ecessary redu cin g
th e stability.
Su rgica l ste p s in d istra ctio n o ste o ge n e sis (Iliza ro v m e th o d )
Segm en tal resection : Th e debridem en t con sists o a
segm en tal resection o th e site o n on u n ion ( Fig 9 .2 -8 ).
Becau se o th e destabilization to be expected, th e
extern al xation m ay be applied prior to th e resection .
Tw o parallel resection osteotom ies are per orm ed to
secu re a large con tact area in th e later dockin g site.
Segm en tal resection tran s orm s th e in ected n on u n ion
in to a de ect n on u n ion . It is essen tial to per orm an
180
adequ ate segm en t rem oval to en su re th at n o residu al
dead bon e is le t at th e m argin s o th e de ect. Con servin g
n on viable bon e com prom ises th e later h ealin g o th e
dockin g site.
Stabilization : A u n ilateral xator ( Fig 9.2-10 ) [4042] or a
circu lar ram e ( Fig 9 .2 .8 , Fig 9.2 -9 , Fig 9 .2 -11 ) [43, 44] can
be ch osen . Th e u se o IM devices is lim ited to cases
w ith a proven sm all risk o recu rren ce o in ection . Th e
xator sh ou ld be bu ilt in a w ay th at a bon e ragm en t
can be tran sported in to th e de ect area con tin u ou sly
an d com pressed in th e dockin g site w ith ou t later
ch an ge o th e ram e system ( Fig 9 .2 -8 , Fig 9 .2 -10 ).
Th e application o th e extern al ixation system s is n ot
particu larly com plicated i per orm ed regu larly. Th e progres-
sive treatm en t, h ow ever, requ ires a m eticu lou s ollow -u p
an d th e ability to adju st th e xator w h en ever n ecessary.
Pin -track in ection , w ire breakage, an d loss o join t m otion
m u st all be addressed qu ickly to preven t perm an en t com -
plication s. It is th e in ten sive a tercare in particu lar th at m akes
an Ilizarov procedu re m ore com plicated th an stan dard or-
th opedic procedu res. Ilizarov treatm en t o in ected n on -
u n ion s sh ou ld be per orm ed in dedicated cen ters th at h ave
su cien t experien ce an d logistical su pport.
Fig 9.2-9 Exam ple of an Ilizarov ring xator applie d for a trifocal
bone transport to re construct a m iddiaphyse al tibial de fe ct. In
this case , the re has be e n a ce ntral se gm e ntal re se ction with two
corticotomie s pe rform e d in the proxim al and distal tibia. The two
bone fragm e nts are the n transporte d towards e ach othe r ove r a thin
intram e dullary wire , to allow docking in the m idtibia.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Johan Lammens, Pe te r E Ochsne r, Martin A McNally

a b

c d
Fig 9.2-10 a d Infe cte d nonunion of the tibia.
a b Tre atm e nt with Ilizarov bone transport using a m onolate ral xator afte r re se ction of an 8 cm bone se gm e nt.
c The skin de fe ct has gradually close d as the ce ntral transport se gm e nt m ove s down the lim b without the ne e d of a skin graft.
d The xator has be e n sim pli e d towards the e nd of tre atm e nt for patie nt conve nie nce .

181
 Se ct io n 2Spe cial
situations
9.2Infe cte d
nonunion
So t-tissu e h an dlin g: Th e so t tissu es sh ou ld be closed
over th e de ect prim arily i possible. Wou n d closu re
sh ou ld n ot be orced a ter bon e resection . Open areas
are covered w ith ban dages m oisten ed w ith an tiseptics
su ch as polyh exan ide. In parallel to bon e tran sportation
th ere is con com itan t n eo-h istiogen esis o th e adjacen t
so t tissu e. Th e so t tissu es are distracted togeth er w ith
th e bon e, w h ich leads to a closu re o th e so t-tissu e
de ect. Th is m ay avoid u rth er recon stru ctive su rgery
or ocu s it at a precise localization at th e en d o th e
distraction ( Fig 9 .2 -10 ). In special situ ation s a separate
progressive traction on th e so t tissu es can be in stalled
w ith stron g su tu res on both edges o th e w ou n d an d
attach ed to th e ram e in a w ay th at a gradu al closu re
can be realized ( Fig 9.2-11 ) [45]. In th is w ay, sign i can t
open skin de ects can be closed du rin g th e bon e
tran sport. How ever, th is can in crease th e risk o
secon dary in ection an d ailu re o h ealin g o th e
dockin g site. As an altern ative, Ilizarov m eth ods can be
com bin ed w ith ree vascu larized tissu e tran s er [46].
Care m u st be taken w ith ram e design to accom m odate
th e bu lk o th e f ap du rin g tran sport. Wh en acu te
sh orten in g is per orm ed, a ree m u scle f ap can be u sed
to cover th e dockin g site. Corticotom y distraction at a
distan t site w ill n ot a ect th e m u scle f ap.
Fig 9.2-11 Gradual side -side closure of the skin is possible with the
xator and e lastic bands.
182
Corticotom y: In severe in ection , particu larly a ter IM
n ailin g, th e corticotom y or segm en tal distraction
sh ou ld be delayed by 12 w eeks a ter th e in itial
segm en tal resection . It is sa er to ch oose th e place or
th e corticotom y at a level w ith as large a diam eter o
th e bon e as possible. For a distal de ect a proxim al
corticotom y is per orm ed an d vice versa. In case o a
cen tral de ect both a proxim al an d distal osteotom y can
dou ble th e speed o callu s distraction bu t th e sh orten in g
o th e total h ealin g period is less im pressive
( Fig 9.2-9 ). Th e corticotom y sh ou ld be don e in a
m in im ally in vasive w ay th rou gh a 12cm in cision
preservin g th e periosteu m an d redu cin g th e dam age to
th e m edu llary bon e. Th e cortex can be w eaken ed w ith
drill h oles an d th e corticotom y com pleted w ith a
ch isel. Th is is tech n ically easier th an th e tech n iqu e
w ith a Gigli saw . Im age in ten si er u se sh ou ld con rm
th at th e corticotom y is com plete to avoid a ailu re o
distraction or a prem atu re u sion .
Bon e distraction : Th e resh osteotom y is distracted
du rin g th e operation by abou t 1 m m [37]. Du rin g th e
ollow in g 710 days (th e laten t period) callu s is orm ed
in th e corticotom y gap. Th en a daily distraction o
0.751 m m is m ade u n til th e desired exten sion is
per orm ed. It is u su al to divide th e daily distraction
in to ou r episodes o 0.25 m m each tim e. Regu lar
review w ith clin ical an d x-ray assessm en t is recom -
m en ded every 2 w eeks du rin g distraction an d every
m on th du rin g con solidation .
Con solidation o th e distraction site: Th e con solidation
o th e distraction site takes as a rou gh ru le 5 ( 2)
m on th s in addition to th e distraction period. Th is
con rm s th at it is n ot w orth retain in g bon e w ith
dou bt u l vitality becau se th e prolon gation o th e
con solidation by resectin g 1 cm m ore is arou n d 10 days.
Con solidation o th e dockin g site: Th e extern al xation
can be con tin u ed till th e com plete h ealin g o th e
dockin g site or m ay be redu ced to a sim pler system
tow ards th e en d o h ealin g ( Fig 9 .2-10d ) [47 ]. Un ion w ith
Ilizarov m eth od alon e an d w ith ou t addition al osteo-
plastic m easu res is ach ieved in 5080% o cases [43 , 4 6 ].
Fu rth er treatm en t m ay be n ecessary su ch as decortica-
tion , can cellou s au togra t, addition o BMP, or secon dary
in tern al xation [46, 48, 49]. Th e u se o secon dary
in tern al xation is associated w ith an in creased
in ection recu rren ce rate [46].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Johan Lammens, Pe te r E Ochsne r, Martin A McNally
3 .3 .6 Fre e va scu la rize d b o n e tra n sfe r
Th e vascu larized bon e tran s er is a distin ct altern ative to
callu s distraction . Vascu larized bon e can be tran s erred alon e
or as a com posite gra t com bin in g bon e, m u scle an d skin .
Th ere are som e clear advan tages o a ree vascu larized bon e
gra t:
Th e tran splan ted gra t is vital an d h as an im m ediate
biological h ealin g poten tial on both o its en ds.
Debridem en t o th e in ected n on u n ion can leave
irregu lar m argin s. Vascu larized gra ts can be adapted to
t th e sh ape o th e de ect.
Ch oosin g a com posite gra t w ith bon e an d skin allow s
th e im m ediate repair o a so t-tissu e de ect at th e sam e
tim e.
Th e recon stru ction can be u n ction al a ter 34 m on th s.
In th e u pper lim b, ree bu lar gra ts are already sim ilar
in size to th e h ost bon es so little rem odelin g an d
h ypertroph y is n eeded.
Th ere are also som e disadvan tages:
Th e th ickn ess an d th e len gth o th e bon e gra ts are
lim ited.
In th e low er lim b, ree bu lar gra ts m u st u n dergo
m ajor h ypertroph y. Th is m ay ail or requ ire a very lon g
period o tim e (> 23 years) resu ltin g in stress ractu res.
Addition al m easu res su ch as can cellou s au togra tin g
m ay be n eeded to im prove stability or secu re u n ion .
To ach ieve bon y in tegration , th ere is n eed or a better
local stability th an is n eeded or con solidation o callu s
distraction or a pu re can cellou s au togra t. Non u n ion at
an in tegration site is com m on .
Th e ollow in g ree vascu larized bon e gra ts are u se u l:
Fibu la alon e or as com posite gra t w ith m u scle an d
skin : Th e bu la is lon gu p to abou t 2025 cm can be
h arvested [50, 51]bu t is th in . With ou t addition al
m easu res it is in su cien t or th e recon stru ction o th e
tibia or th e em u r. Becau se o m ech an ical in su cien cy
atigu e ractu res o th e gra t m ay h appen [52]. Dou ble
gra tin g u sin g th e sam e bu la is possible. Problem s o
th e don or site are n ot rare, particu larly i a skin paddle
is taken w ith th e bu la.
Scapu la: Th e bon e o th e m edial border is th in , bu t
m ay h ave a rem arkable exten t u p to 8 x 2 cm . A
com posite gra t w ith m u scle an d skin is th e ru le. To
recon stru ct a u ll diam eter o a tu bu lar bon e it n eeds
addition al osteoblastic m easu res, m ain ly can cellou s
au togra t ( Fig 9 .2 -12 , Fig 9 .2 -13 ).
Medial em oral con dyle: Th is is a pu re bon e gra t w ith
a m axim u m exten t o abou t 4 x 2 cm .
Iliac crest as a com posite gra t w ith m u scle u p to th e
exten t o 8 x 2 cm .
Part o a rib w ith adjacen t tissu e u p to abou t 6 cm o
len gth . Not o ten con sidered ou tside th e h an d or oot
du e to poor bon e qu ality an d rib cu rvatu re.
Free vascu lar bon e gra ts requ ire th e skills o th e orth opedic
su rgeon an d a m icrovascu lar plastic su rgeon . Care u l pre-
operative plan n in g is n eeded to de n e th e resection , site o
th e vascu lar an astom osis an d stabilization o th e gra t. Th e
xation o th e gra t in th e n on u n ion site m u st be very stable.
Th is can be ach ieved w ith an extern al xator produ cin g
com pression across th e gra t. I a rigid plate is u sed, th is m ay
stress sh ield th e gra t an d preven t h ypertroph y. Good stabil-
ity is o ered by an in terlockin g n ail ( Fig 9.2-12 , Fig 9 .2 -13 ) bu t
addition al xation m ay be n eeded or a better in tegration
o th e gra t. Stabilization m u st allow im m ediate join t m otion
an d early w eigh t bearin g. In th e low er lim b, im m obilization
m ay be n eeded or m an y m on th s du rin g gra t rem odelin g.
183
 Se ct io n 2Spe cial
situations
9.2Infe cte d
nonunion

a b c

d e
Fig 9.2-12 a e Se ve re ope n tibial fracture by a dire ct traum a in a 2 5 -ye ar-old man.
a Local com minution and displace m e nt; plate oste osynthe sis is de cide d.
b Within 6 m onths the re was spontane ous re sorption of the proxim al tibial fragm e nt (arrows) with re sulting instability. Infe ction with
e nte rococci and clostridia. De bridm e nt and lling of the 5 cm de fe ct with a m ixture of m orce lize d auto- and allograft and pie ce s of
collage n sponge containing ge ntamicin followe d.
c Vanishing of the graft within 7 m onths (se e Fig 9.12-13 ), no re m aining infe ction.
d The infe cte d de fe ct was re se cte d and lle d with a vascularize d com posite bone , m uscle and skin ap from the scapula with stable
xation using a nail and sm all plate s and additional cance llous autograft.
e Full union with incorporation of the graft is se e n at 9 m onths.

184 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Johan Lammens, Pe te r E Ochsne r, Martin A McNally

Fig 9 .2 -13 a c Sam e case as Fig 9.2-12 . Failure of bridging of an

infe cte d nonunion with a com posite graft containing m orse lize d auto-
and allograft and pie ce s of collage n sponge containing ge ntamicin.
a Re se cte d 4 cm long se gm e nt of faile d re construction, m ainly
consisting of soft tissue containing brittle parts ( b), only at one
place having a bony re sistance (c).
b Histological analysis (unde calci e d, Rom anowsky stain) of the
ne crotic graft mate rial without any ne w bone formation.
c
c Single are a of ne w bone form ation ( bright blue) around som e
cance llous autogaft pie ce s.

185
 Se ct io n 2Spe cial
situations
9.2Infe cte d
nonunion
3 .4 Clo s u re o f s k in d e fe ct s
Th e so t-tissu e situ ation w ill determ in e w h eth er w ou n d
closu re will requ ire recon stru ctive su rgery u sin g ( ree) tissu e
f aps or n ot. Th e treatm en t o in ected n on u n ion is u su ally
n ot u rgen t so a u ll assessm en t an d discu ssion w ith a plastic
su rgeon can be arran ged.
Th e m ost im portan t m ean s to cover de ects are:
Sim ple split-skin gra ts on a w ell gran u lated bed
Local rotation f aps (eg, gastrocn em iu s m u scle f ap)
Free vascu larized skin f aps (eg, lateral u pper arm f ap,
w h ich allow s in n ervation ), com bin ed skin an d m u scle
f aps (eg, latissim u s dorsi f ap) or m u scle f aps (eg,
gracilis f ap)
Th ere m ay be sign i can t advan tages in u sin g ree or local
m u scle f aps arou n d in ected n on u n ion s. Th e f aps h ave
been sh ow n to resist in ection , provide n eo-vascu larization
o th e bon e rom th e m u scle, deliver h igh levels o an tibi-
otic to th e site an d recru it stem cells or tissu e h ealin g. In
th e low er leg, th ey also provide a good bu lk o tissu e over
th e su bcu tan eou s an terior border o th e tibia, redu cin g th e
risk o later in ju ry cau sin g bon e exposu re.
Negative-pressu re w ou n d th erapy alon e is n ot in dicated in
so t-tissu e m an agem en t o in ected n on u n ion s, u n less it is
u sed in com bin ation w ith recon stru ctive su rgery. Som e
tech n iqu es or th e bon y recon stru ction can prom ote so t-
tissu e h ealin g. Th is is th e case or th e Papin eau tech n iqu e,
bu t th e resu ltin g scar tissu e w ith or w ith ou t split-skin gra t
resu lts requ en tly in an u n stable scar ( Fig 9.2-6 ). Th e bon e
tran sport m eth od in parallel can be accom pan ied w ith a de
n ovo so t-tissu e regen eration ( Fig 9 .5 .10 , Fig 9.2-11 ).
186
4 Co m p lica t io n s a n d o u t co m e s
An in ected n on u n ion is a com plex problem requ irin g a lon g
cou rse o treatm en t, o ten w ith m u ltiple su rgeries. To som e
exten t it h as to be con sidered as a resection -recon stru ction
procedu re w ith th e n al aim to eradicate th e in ection , to
recon stru ct th e bon e or u ll w eigh t bearin g an d to regain
a u lly u n ction al extrem ity. Th e im portan t prin ciples to
avoid recu rren ce are th e radical resection o th e in ected
area, th e adju van t an tibiotic th erapy o an adequ ate len gth ,
dictated by care u l tissu e sam plin g an d cu ltu re, ollow ed by
th e early closu re o an y so t-tissu e de ect. Failu re to address
an y o th ese issu es w ill in crease th e ch an ce o recu rren t
in ection an d persisten t n on u n ion . In m ost series, u p to
20% o cases w ill su er on e or both o th ese com plication s,
requ irin g u rth er in terven tion . How ever, a ter com plete
treatm en t, arou n d 90% o cases can be su ccess u lly h ealed
[43, 46, 5355].
Restoration o u ll u n ction is di cu lt in th ese cases as m an y
patien ts h ave already developed join t con tractu res an d
ch ron ic pain prior to th e de n itive treatm en t o th eir n on -
u n ion .
Delays in w ou n d h ealin g are ru stratin g or patien ts. Open
w ou n d tech n iqu es o ten requ ire exten sive n u rsin g care an d
prolon ged tim e in h ospital, n ally produ cin g an u n stable
an d vu ln erable scar. As a resu lt, com bin ed recon stru ction
o th e bon e an d so t tissu es w ith ree tissu e tran s er is n ow
m ore com m on . Th is can sa ely be per orm ed as a sin gle
procedu re [46] or can be staged.
Th e produ ction o advan ced th erapy m edicin al produ cts
(ATMPs) con tain in g expan ded stem cells seeded on a ab-
sorbable sca old an d au gm en ted w ith bon e-in du cin g m ol-
ecu les are prom isin g bu t n ot yet applicable in rou tin e su rgery.
Th ere ore, th e bon e tran sport m eth ods developed by GA
Ilizarov rem ain th e sa est, least soph isticated, an d m ost
econ om ical treatm en t m eth od available or large bon e de ects
resu ltin g in u n ction al bon e replacem en t.
5 Co n clu s io n
Th e cu rren tly available tech n iqu es are dem an din g, expen sive
an d rem ain w ith som e com plication s an d problem s. Th ey
requ ire exten sive su rgical skill. In th e u tu re, w e n eed m eth -
ods w h ich are m ore easily tolerated by patien ts an d appli-
cable in resou rce-poor parts o th e w orld, w h ere in ected
n on u n ion is com m on .
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Johan Lammens, Pe te r E Ochsne r, Martin A McNally
6 Re fe re n ce s
1. Ro s e n H. Treatm en t o n on u n ion :
gen eral prin ciples. In : Ch apm an W, ed.
Operative Orthopaedics, Ph iladelph ia:
Lippin cott-Raven ; 1988:4 89 509.
2. Ja in AK, Sin h a S. In ected n on u n ion o
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com bin ed u se o th e Ilizarov m eth od
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Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Antonia F Chen, Carlo L Roman, Lorenzo Drago, Javad Parvizi
10 In fe ctio n a fte r jo in t a rth ro p la s t y
An to nia F Ch e n, Carlo L Rom an , Lo re nzo Drago, Javad Parvizi
1 Ba s ics
Periprosth etic join t in ection (PJI) a ter total join t arth ro-
plasty (TJA) is a devastatin g com plication . With th e in crease
in th e n u m ber o TJA cases per orm ed an n u ally, th ere w ill
be a correspon din g rise in th e n u m ber o PJI w ith all o its
associated m orbidity, m ortality, an d costs to society. Th u s,
it is im perative to u n derstan d th e etiology o PJI an d e ective
strategies th at exist to m an age th ese. Th orou gh kn ow ledge
o th e e ective m eth ods in preven tion , diagn osis, an d
treatm en t o PJI is requ ired. An in ection arou n d a prosth e-
sis u su ally presen ts in an elu sive m an n er an d m ay evade
detection u n less a h igh in dex o su spicion is m ain tain ed.
Th u s, an y patien t w ith a pain u l prosth etic join t n eeds to
be su bjected to a th orou gh h istory takin g, clin ical exam in a-
tion , an d laboratory an d im agin g in vestigation to con rm
or re u te th e diagn osis o PJI. On ce diagn osed, selection o
th e m ost appropriate su rgical treatm en t com bin ed w ith
an tibiotic th erapy is critical or an optim al ou tcom e.
1.1 Et io lo g y
Th e etiology o in ection a ter arth roplasty varies an d in clu des
en dogen ou s an d exogen ou s sou rces [1]. Con tam in ation rom
w ith in th e join t at th e tim e o in dex TJA m ay presen t as an
in ection th at persists in th e im m ediate postoperative pe-
riod, or presen t later as an in dolen t in ection . Late in ection s
w ith acu te presen tation s o ten resu lt rom h em atogen ou s
spread rom oth er n idu s o in ection , su ch as oral or u rin ary
sou rces. In ection s can also spread rom con tigu ou s or direct
sou rces, su ch as localized abscesses arou n d th e join t. Fin ally,
in ection s m ay occu r as a resu lt o system ic sepsis or in th e
settin g o a previou sly septic join t.
1.2 Lo ca liza t io n
Com m on ly replaced join ts are th e kn ee, h ip, sh ou lder, elbow ,
an d an kle. All can becom e in ected. Periprosth etic join t in -
ection presen ts special diagn ostic ch allen ges w h en com pared
w ith oth er types o in ection s. It m ay be di cu lt to diagn ose
PJI, as isolation o bacteria rom th e join t m ay be di cu lt
in approxim ately 30% o cases. Man y cases presen t w ith a
pain u l join t bu t n o visible sign s as w ou ld be ou n d in cel-
lu litis or oth er in ection s, ie, eryth em a, w arm th , f u ctu an ce,
or ten dern ess. Th u s, clin ician s m u st rely on a h igh in dex o
clin ical su spicion based on h istory, presen tin g sym ptom s,
im agin g, an d diagn ostic w orku p to reach th e diagn osis o
an in ection a ter arth roplasty. Aspiration o th e join t an d
obtain in g tissu e sam ples or cu ltu re are th e m ost im portan t
critical in itial steps or diagn osis o PJI. I m u ltiple join ts
h ave been replaced in a patien t it is im portan t to evalu ate,
exam in e, an d possibly aspirate each on e o th em .
1.3 In cid e n ce
Th e in ciden ce o PJI m ay be u n derestim ated, as approxi-
m ately 30% o th ese cases are cu ltu re-n egative an d m ay
n ot be reported as an in ection . Th e prevalen ce o PJI is on
th e rise w orldw ide as m ore an d m ore cases o arth roplasty
are per orm ed [2]. Th e in ciden ce o PJI depen ds largely on
w h at criteria are u sed to de n e th is en tity. Th e de n ition
o PJI h as ch an ged over tim e. Tradition ally, th e de n ition
o prosth etic join t in ection w as based on th e criteria set
orth by th e Cen ters or Disease Con trol [3]. How ever, based
on th e m ore re n ed de n ition o PJI detailed below , th e
in ciden ce o PJI in th e Un ited States rom 20012009, u sin g
a n ation al database, w as ou n d to be betw een 22.4% . Based
on a projection stu dy u sin g th e Nation al In patien t Sam plin g
database, Ku rtz et al [4] predicted th at th e total n u m ber o
PJI cases w ou ld be on th e rise on an alm ost expon en tial
trajectory. A later stu dy u sin g th e sam e database con rm ed
th eir in itial projection prediction s an d stated th at th e n u m -
ber o PJI cases w ou ld rise to 65,555 per year by 2020 [5].
A sim ilar tren d, n am ely a su bstan tial rise in th e n u m ber o
PJIs, h as also been w itn essed in Eu ropean cou n tries th rou gh
registry data an d data rom in dividu al h ospitals [2, 6, 7].
189
 Se ct io n 2Spe cial
situations
10
Infe ction
after
joint
arthroplasty

1.4 Ris k fa ct o rs To low er th e risk o PJI, certain preoperative steps m ay be

Th ere h ave been n u m erou s stu dies attem ptin g to evalu ate
th e risk o a patien t or PJI. Alth ou gh patien ts w ith seem -
in gly n o risk actors or in ection can develop PJI, th e m ajor-
ity o patien ts th at develop PJI h ave iden ti able risk actors.
Th e risk actors or PJI can be con ven ien tly divided in to
h ost-related, su rgical, an d postoperative actors.
In ection arou n d a prosth esis is likely to occu r wh en in ectin g
organ ism s n d access to th e im plan t. Du rin g an episode o
bacterem ia, th e ability o a h ost to clear blood-born e path ogen s
depen ds on th e patien ts im m u n e system . Th u s, an y im m u n e-
com prom isin g con dition s su ch as can cer, diabetes, h u m an
im m u n ode cien cy viru s, an d in f am m atory arth ropath ies
w ou ld place th e patien t at a h igh er risk or PJI. Oth er m od-
i able risk actors, su ch as obesity w h ich is de n ed as body
m ass in dex > 35 kg/ m 2 , excessive alcoh ol con su m ption , h eavy
sm okin g, an d in traven ou s dru g u se, h ave also been associ-
ated with an in creased risk or PJI [813]. Som e n on m odi able
risk actors or PJI in clu de older age [4, 14] an d m ale sex [15,
1 6] ( Ta b le 10 -1 ). Patien ts w ith oth er m edical com orbidities
su ch as cardiopu lm on ary com orbidities, depression , h em o-
ph ilia, h epatitis C, m aln u trition , h yperten sion , ren al disease,
liver disease, sickle cell h em oglobin opath ies, an d psoriasis
also h ave a h igh er risk or in ection [8, 11, 13, 1723]. Fin ally,
h istory o recen t or rem ote in ection s su ch as previou s in ec-
tion s in th e sam e join t [24, 25], previou s orth opedic in ection s
[2 6 ], colon ization w ith m eth icillin -resistan t Staphylococcus
aureus (MRSA) [13], an d u rin ary tract in ection s [8, 27] m ay
predispose patien ts to developin g PJI.
taken . Recen t stu dies h ave iden ti ed som e o th ese e ective
preven tative m eth ods. A recen t In tern ation al Con sen su s on
PJI [2 8 ] evalu ated all available literatu re pertin en t to th e
m itigation o risks or PJI an d iden ti ed th e ollow in g as
eviden ce-based strategies or preven tion o su rgical-site in -
ection s or PJI. Th e u se o ch lorh exidin e skin w ipes or soaps
prior to elective TJA h as been sh ow n to be a very e ective
strategy or m in im izin g su rgical-site in ection s in clu din g PJI
an d w as stron gly en dorsed by th e In tern ation al Con sen su s
Grou p (ICG) [29]. Optim ization o m edical con dition s prior
to arth roplasty, appropriate preparation o th e skin w ith
agen ts con tain in g alcoh ol, an d clippin g o th e h air arou n d
th e in cision site u sin g clippers ju st prior to su rgery w ere
som e o th e oth er e ective m eth ods th at are believed to be
im portan t or th e preven tion o PJI. Perh aps on e o th e m ost
critical aspects o in ection preven tion , w h ich in ciden tally
h as n ever been stu died in a ran dom ized an d prospective
m an n er, in clu des tim ely an d dose-based adm in istration o
perioperative an tibiotics. At th is poin t, both th e ICG an d
th e Cen ters or Disease Con trol believe th at rst-gen eration
ceph alosporin s or syn th etic pen icillin s are still th e best agen ts
or th is pu rpose. Th ere are, h ow ever, occasion s w h en an
addition al an tibiotic n eeds to be u sed. For patien ts w ith
pen icillin allergies, van com ycin , carbapen em s, teicoplan in ,
or clin dam ycin m ay be adm in istered. Van com ycin m ay also
be adm in istered in patien ts w h o h ave a h istory o MRSA
[30]. It is critical to n ote th at van com ycin is n ot a pre erred
agen t again st m eth icillin -sen sitive S aureus or oth er gram -

Mo d i a b le ris k fa ct o rs fo r PJI No n m o d i a b le ris k fa ct o rs fo r PJI

Fa ct o r Mo d i ca t io n Fa ct o r
Obesity Lose weight to body mass index < 40 kg/m2 Older age
Smoking Decrease/cease smoking Malignancy
Diabetes Reduce HbA1c < 78 Rheumatoid arthritis
IVdrug use Stop drug use Liver disease
Alcohol consumption > 4 units/day Reduce/stop alcohol consumption Renal failure
Immunosuppressive drugs Stop certain medications prior to surgery Sickle cell disease
Anemia Iron supplementation, erythropoietin Hepatitis C
Malnutrition (low albumin/protein/prealbumin/transferrin) Improve diet with protein HIVinfection
Staphylococcus carrier Decolonize patient Male gender
Psoriasis
Cardiopulmonary disease
Transplant patients

Ta b le 10 -1 Modi able and nonm odi able risk factors for de ve loping a prosthe tic joint infe ction.
Abbre viations: PJI, pe riprosthe tic joint infe ction; IV, intrave nous; HbA1c, glycosylate d he m oglobin; HIV, hum an im m unode cie ncy virus.

190 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Antonia F Chen, Carlo L Roman, Lorenzo Drago, Javad Parvizi
positive agen ts, an d h en ce its u se sh ou ld be com bin ed w ith
an oth er agen t w ith broader activity again st oth er organ ism s.
Th ere are a n u m ber o w ell-kn ow n su rgical in terven tion s
th at can be im plem en ted to redu ce th e risk o PJI. Redu ction
o operative tim e, m in im izin g so t-tissu e dissection , th e u se
o region al an esth esia, redu ction o blood loss w ith th e u se
o agen ts su ch as tran exam ic acid, th e u se o clean operatin g-
room system s, an d th e u se o occlu sive dressin gs are ex-
am ples o su ch m eth ods [17, 3134].
Perh aps on e o th e m ost im portan t an d yet u n derstu died
aspects o PJI preven tion relates to th e u se o strin gen t post-
operative protocols. E orts to m in im ize h em atom a orm ation ,
redu ce w ou n d drain age, an d optim ally m an age m edical
con dition s su ch as diabetes, arrh yth m ia, an d cardiac con di-
tion s are im portan t postoperative steps th at can h elp redu ce
th e in ciden ce o PJI. In recen t years, m ore e orts h ave been
in vested to redu ce th e n eed or allogen eic tran s u sion , w h ich
by virtu e o im m u n om odu lation , can in crease th e risk o
su rgical-site in ection an d PJI [3 5 ]. Th e adm in istration o
in traoperative tran exam ic acid, th e u se o h ypoten sive re-
gion al an esth esia, an d th e u se o less aggressive an ticoagu lan ts
are all exam ples o su ch e orts to redu ce blood loss an d
h em atom a orm ation [36].
1.5 Cla s s ifica t io n
Th ere are m u ltiple classi cation system s or PJI, som e u sin g
th e tim e rom in dex arth roplasty to diagn osis, du ration o
sym ptom s, h ost actors, an d th e type o m icroorgan ism s
cau sin g th e in ection . Th e m ost com m on ly u sed system is
th e Tsu kayam a classi cation , w h ich provides a gu idelin e
or su rgical in terven tion [3739]. Based on th at classi cation ,
an early in ection is on e th at occu rs w ith in 1 m on th o th e
in dex procedu re an d m ay be treated w ith irrigation , debride-
m en t, exch an ge o m obile parts (i possible), an d appropriate
an tibiotic th erapy. Late ch ron ic in ection s occu r m ore th an
1 m on th a ter th e in dex procedu re an d sh ou ld be treated
by a on e- or tw o-stage exch an ge arth roplasty procedu re.
Acu te h em atogen ou s in ection s m ay occu r late in th e settin g
o a w ell- u n ction in g join t replacem en t. Su ch cases m ay be
treated by irrigation , debridem en t, exch an ge o m obile parts
w ith prosth esis reten tion , an d adm in istration o in traven ou s
an tibiotics.
Th e Zim m erli classi cation is a m odi cation o th e Tsu kaya-
m a classi cation th at stretch es th e tim e periods or each
category. Acu te in ection is de n ed as on e th at occu rs with in
3 m on th s o th e in dex procedu re, delayed in ection s occu r
betw een 324 m on th s a ter th e in dex procedu re, an d late
in ection s occu r m ore th an 24 m on th s a ter th e in dex pro-
cedu re [40 ]. Th is classi cation system proposes th at acu te
in ection s are m ost likely du e to seedin g o organ ism s in to
th e join t at th e tim e o in dex arth roplasty, wh ile late in ection s
m ay be cau sed by h em atogen ou s spread rom an oth er sou rce
o in ection or by in dolen t organ ism s in ocu lated at th e tim e
o th e in itial su rgery. Th e etiology o late in ection s is n ot
w ell described in th is system .
Fin ally, th e McPh erson classi ication evalu ates m u ltiple
actors, in clu din g tim in g, h ost actors, an d a local extrem ity
grade. In ection s occu rrin g w ith in 4 w eeks o th e su rgical
procedu re are early postoperative in ection s. Late in ection s
occu r a ter 4 w eeks an d m ay h ave ch ron ic sym ptom s [41].
System ic h ost actors are graded in to th ree categories sim i-
larly to th ose previou sly proposed in th e Ciern y-Mader
classi cation [42]. Host type A is u n com prom ised, h ost type
B h as on e to tw o com prom isin g actors, an d h ost type C h as
tw o or m ore com prom isin g actors, su ch as ch ron ic active
in ection s at oth er location s or th e presen ce o a n eoplasm .
Th e local extrem ity grade is a ratin g o th e local w ou n d
in ection site based on actors th at m ay com prom ise h ealin g,
an d is graded rom 1 (n o com prom ise) to 3 (tw o or m ore
com prom isin g actors). Th e presen ce o so t-tissu e loss, m u l-
tiple in cision s, su bcu tan eou s abscesses, stu las, vascu lar
in su cien cy, an d previou s trau m a an d/ or irradiation are
all com prom isin g actors th at m ay a ect a patien ts ability
to h eal rom a PJI. Th is classi cation system is th e m ost
com preh en sive an d clin ically relevan t o all classi cation
system s. Based on th is classi cation , a patien t w ith early
in ection w h o h as com prom ised so t tissu es an d/ or a com -
prom ised h ost m ay n ot be a can didate or irrigation an d
debridem en t w ith reten tion o th e prosth esis.
191
 Se ct io n 2Spe cial
situations
10
Infe ction
after
joint
arthroplasty
2 Sym p t o m s
Patien ts w h o presen t w ith PJI m ay h ave overt or su btle
sym ptom s o in ection . Classically, an in ected join t is ex-
pected to h ave redn ess, sw ellin g, h eat rom th e w ou n d,
pain , an d loss o u n ction . An exam ple o in ected total kn ee
arth roplasty w ith eryth em a an d edem a is seen in Fig 10-1 .
How ever, m an y patien ts w ith PJI can presen t w ith su btle
sign s o in ection an d m ay exh ibit n on e o th e sym ptom s
listed above. Pain is th e m ost com m on presen tin g sym ptom
o PJI [43 ]. An y patien t presen tin g w ith pain u l prosth etic
join t sh ou ld be evalu ated or PJI.
Fig 10 -1 An e xam ple of infe cte d total kne e arthroplasty with
e rythe m a and e de m a.
192
3 Dia gn o s t ic w o rku p
Th e diagn osis o PJI is ch allen gin g an d requ ires a m u lti ac-
eted approach . Th e w orku p o th ese patien ts in volves takin g
a th orou gh h istory, per orm in g detailed ph ysical exam in a-
tion , an d orderin g th e appropriate tests. Th e ICG on PJI
proposed an algorith m ic approach to th e diagn osis o PJI
th at in clu des per orm in g serological laboratory tests ollow ed
by aspiration o th e join t ( Fig 10-2 ). Th e aspirate sh ou ld be
an alyzed or n eu troph il cou n t, polym orph on u clear (PMN)
percen tage, an d sh ou ld also be cu ltu red. In recen t years,
th e role o m olecu lar biom arkers or diagn osis o PJI h as
been in vestigated w ith syn ovial -de en sin sh ow in g th e
greatest prom ise am on g all th e m arkers w ith a sen sitivity
o 97% an d speci city o 100% or th e diagn osis o PJI [44].
3 .1 Pa t ie n t h is t o r y
A patien ts h istory sh ou ld be th e rst step towards diagn osin g
an in ected arth roplasty. Patien ts sh ou ld be asked abou t
recen t in ection exposu re an d procedu res, as well as sym ptom s
an d th eir begin n in g.
Patien ts are at in creased risk o PJI in th e presen ce o an
in ection or in f am m atory process in an oth er part o th e
body, su ch as th e gen itou rin ary, respiratory, cardiac, gas-
troin testin al, skin , an d bloodstream in ection s. Th e recen t
u se o an tibiotics is o ten in dicative o a poten tial in ectiou s
agen t th at m ay seed th e join t an d resu lt in an in ected ar-
th roplasty. Patien ts sh ou ld be asked abou t th e sym ptom s o
u rin ary tract in ection , su ch as u rgen cy, dysu ria, requ en cy,
or u rin ary reten tion [45 47 ]. Patien ts sh ou ld also be asked
abou t respiratory sym ptom s, su ch as cou gh , dyspn ea, an d
spu tu m produ ction , w h ich m ay im plicate th e u pper respira-
tory tract as th e sou rce o possible PJI. En docarditis can be
a cardiac sou rce o in ection [48], w h ile ch olan gitis an d ch o-
lecystitis rom th e gastroin testin al tract can also seed a pros-
th etic join t [49 , 50 ]. Fin ally, in ection s in oth er parts o th e
body, su ch as th e oral cavity an d th e large in testin e, m ay
con tain abscesses th at lead to bacterem ia an d poten tial or
seedin g o prosth etic join ts. Staph ylococcal bacterem ia h as
been reported to h ave a 30% risk o PJI [51].
In vasive procedu res per orm ed on th e body m ay also release
bacteria in to th e bloodstream an d predispose patien ts w ith
prosth etic join ts to PJI. In vasive den tal procedu res, su ch as
drain age o a periapical abscess, m ay resu lt in th e release o
bacteria rom th e oral cavity su ch as Treponema denticola,
Actinomyces israelii, Actinomyces naeslundii, an d Streptococcus
viridans an d Streptococcus oralis [45, 47, 52, 53]. Gastroin testin al
procedu res su ch as colon oscopies an d en doscopies m ay resu lt
in release o gram -n egative organ ism s su ch as Escherichia coli
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Antonia F Chen, Carlo L Roman, Lorenzo Drago, Javad Parvizi

Major criterion: Minor criteria:

Sinus tract communicating with the joint Culture
Leukocyte esterase
Synovial white blood cell count
Synovial neutrophil percentage

Normal ESR and CRP History

AND Physical examination (PE)
Presence of major criteria
Low probability of infection X-ray (joint specific)
(based on history/PE/x-ray) Serology (ESR and CRP)

Abnormal ESR and/or CRP

OR
Higher probability of infection
(based on history/PE/x-ray)
without major criteria

Culture positive and one minor criteria

All minor criteria negative Joint aspiration OR
Minor criteria three positive

No fluid
OR
Culture-positive without other positive
minor criteria
OR
One or two positive minor criteria
OR
Clinical suspicion persists without positive
minor criteria

Repeat aspiration with addition of AFB/ Culture positive

All minor criteria negative OR
fungal cultures
Minor criteria two positive

No fluid
OR
Culture-negative and only one minor
criteria positive

In ection unlikely Negative Biopsy (micro AND histology) Positive In ection likely

Fig 10 -2 Algorithm for diagnosing pe riprosthe tic joint infe ction.

Abbre viations: ESR, e rythrocyte se dim e ntation rate; CRP, C-re active prote in; PE, physical e xam ination; AFB, acid-fast Ba cillus.
(Re printe d with pe rm ission from: Pa rvizi J, Ge hrke T. Proce e dings of the Inte rna tiona l Conse nsus Me e ting on Pe riprosthe tic
Joint Infe ction. Towson: Data Trace Publishing Com pany; 2013:16 0 .)

an d Klebsiella pneumoniae [54]. Addition ally, an y recen t su r-
gical procedu re w h ere th e skin h as been com prom ised can
in crease th e bu rden o com m en sal organ ism s, su ch as S au-
reus an d Staphylococcus epidermidis [55]. Askin g patien ts abou t
recen t procedu ral h istory m ay h elp targeted in vestigation s
or isolation o speci c organ ism s em an atin g rom th ese
sou rces.
Detailed qu estion in g sh ou ld be con du cted to in qu ire abou t
th e du ration o sym ptom s, as th is can dictate th e poten tial
treatm en t regim en or th e patien t. Sym ptom s th at h ave an
on set w ith in 4 w eeks a ter th e in dex arth roplasty or h ave
a du ration o less th an 46 w eeks m ay be treated by less
in vasive su rgical m easu res, su ch as irrigation an d debride-
m en t com bin ed, i possible, w ith exch an ge o m obile parts
togeth er w ith adm in istration o an tibiotics. Sym ptom s th at
occu r m u ch later a ter th e in dex procedu re an d are greater
th an 46 w eeks in du ration m ay in dicate ch ron ic in ection
an d requ ire m ore aggressive su rgical m easu res, su ch as on e-
or tw o-stage exch an ge arth roplasty.

193
 Se ct io n 2Spe cial
situations
10
Infe ction
after
joint
arthroplasty

3 .2 La b o ra t o r y Th e m in or criteria m u st be u sed in con ju n ction w ith oth er

Th e diagn osis o PJI can be di cu lt to establish in som e
cases. Th ere are n o speci c tests th at h ave been developed
or th is pu rpose. Tradition ally, th e w orku p o PJI starts w ith
orderin g screen in g serological tests, su ch as eryth rocyte
sedim en tation rate (ESR) an d C-reactive protein (CRP). Al-
th ou gh tradition ally ordered, seru m w h ite blood cell (WBC)
cou n t h as been sh ow n to h ave a very low sen sitivity or
diagn osis o PJI an d h as been aban don ed by m ost as part o
a rou tin e w orku p [56]. Th e n ext step in diagn ostic w orku p
in clu des aspiration o th e join t. Th e join t aspirate is sen t or
n eu troph il cou n t, PMN percen tage, an d cu ltu re. As already
m en tion ed, in recen t years, addition al tests o th e syn ovial
f u id su ch as leu kocyte esterase an d m olecu lar biom arkers
h ave also been proposed th at m ay provide addition al data
poin t or diagn osis o PJI [57]. Microbiological cu ltu res can
be obtain ed preoperatively rom syn ovial f u id aspirates, or
in traoperatively rom syn ovial f u id or tissu e sam ples.
tests, as n o sin gle test pain ts a clear pictu re o PJI. For
exam ple, ESR an d CRP are elevated w h en in f am m ation is
presen t an d are n on speci c or PJI. Th e th resh old level or
th ese tests is also depen den t on th e laboratory w h ere th e
test is per orm ed. Depen din g on th e laboratory n orm al
valu es, a n orm al ESR is less th an 30 m m / h an d a n orm al
CRP is less th an 1.0 m g/ dL or 10 m g/ L. Wh en orderin g CRP
tests, on e m u st order a qu an titative CRP an d n ot a h igh -
sen sitivity CRP or u ltrasen sitive CRP, u n less a con version
actor is applied [6 0 ]. On e m u st also take th e tim in g o
in ection in to accou n t, as ESR an d CRP are elevated in th e
early postoperative period. Eryth rocyte sedim en tation rate
is elevated u p to 6 w eeks a ter su rgery an d CRP is elevated
u p to 2 w eeks a ter su rgery. Th u s, th ese tests m ay h ave
little u tility in th e early postoperative period or diagn osin g
PJI. Bu t i u sed repeatedly th ey can provide im portan t
in orm ation on th e kin etics o th e CRP.

As th ere is cu rren tly n o absolu te test or diagn osis o PJI, a Th e criteria or elevated syn ovial WBC cou n t an d syn ovial
w orkin g grou p rom th e Mu scu loskeletal In ection Society PMN percen tage can also be a ected by th e tim in g o in ection
(MSIS) proposed a diagn ostic criteria or PJI [58]. Th e MSIS an d th e join t bein g in vestigated. Nu m erou s stu dies h ave
criteria or PJI w ere recen tly sligh tly m odi ed by th e ICG been con du cted w ith each proposin g a di eren t th resh old
[59]. Th e de n ition o PJI based on th e ICG m odi cation o or th e level o syn ovial f u id WBC cou n t an d PMN percen t-
th e MSIS criteria is presen ted in Ta b le 10 -2 . A PJI is believed age. Th e valu es h ave varied betw een 1,1003,450 cells/ L
to exist w h en eith er a sin gle m ajor criterion or th ree m in or or th e syn ovial WBC cou n t an d 6478% or PMN percen tage
criteria are presen t. or ch ron ic in ection s [6163]. On th e oth er h an d, or acu te
PJI (less th an 6 w eeks) th e th resh old or syn ovial WBC cou n t
an d PMN percen tage h ave been sh ow n to be h igh er [64, 65].
Th e valu es or each o th ese tests depen d on th e tim e a ter
th e in dex TJA, an d on th e m eth od u sed to m easu re th ese
valu es. Tradition ally, syn ovial WBC cou n t an d PMN percen t-
Major criteriaone present or PJI Minor criteriathree o f ve present age h ave been per orm ed m an u ally. In recen t years, alm ost
or PJI
all laboratories arou n d th e w orld h ave con verted to au to-
1. Two positive periprosthetic cultures with 1. Elevated serum CRP and ESR m ated or sem iau tom ated m eth ods or m easu rin g th ese
phenotypically identical organisms
valu es. Th u s, it is u n clear w h at in f u en ce au tom ated m ea-
2. Asinus tract communicating with the 2. Elevated synovial fluid WBC count or ++
joint change on leukocyte esterase test strip su rem en t o WBC cou n t an d PMN percen tage h as on th eir
3. Elevated synovial fluid polymorphonuclear valu e.
neutrophil percentage
4. Positive histological analysis of Addition ally, seru m WBC, syn ovial f u id WBC, PMN per-
periprosthetic tissue cen tage, an d cu ltu re can all be con ou n ded by actors su ch
5. Single positive culture as th e adm in istration o an tibiotics. A recen t stu dy dem on -
strated th at th e adm in istration o an tibiotics can sign i -
Ta b le 10 -2 The Inte rnational Conse nsus Group de nition for
pe riprosthe tic joint infe ction.
can tly redu ce th e detection o PJI based on positive syn ovial
Abbre viations: PJI, pe riprosthe tic joint infe ction; CRP, C-re active f u id an d tissu e cu ltu res rom 87% w ith ou t an tibiotics to
prote in; ESR, e rythrocyte se dim e ntation rate; WBC, white blood ce ll. 73% w ith an tibiotics [66].

194 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Antonia F Chen, Carlo L Roman, Lorenzo Drago, Javad Parvizi
Th e literatu re h igh ligh ts th e ch allen ges th at exist w ith regard
to in terpretation o th e resu lts o tests th at are ordered du rin g
w orku p o PJI. It is clear th at th e serological an d syn ovial
test resu lts are in f u en ced by n u m erou s actors. How ever,
in an attem pt to stan dardize th e diagn ostic protocol or PJI,
th e MSIS an d th e ICG h ave proposed a th resh old or each
o th ese diagn ostic param eters ( Ta b le 10 -3 ).
An oth er criterion or diagn osin g PJI is th e h istological an al-
ysis o syn ovial f u id or tissu e cu ltu re. In m an y acilities,
th is is a com m on ly u sed test, bu t it m ay be u n reliable. Th is
test is depen den t on a n u m ber o variables, in clu din g th e
location w h ere th e tissu e sam ple w as taken , h ow th e test
slide w as prepared, an d th e path ologist review o th e slides.
Cou n tin g th e n u m ber o n eu troph ils can be su bjective an d
is based on train in g an d experien ce. Addition ally, di eren t
sam ples o tissu e m ay h ave di eren t n eu troph il cou n ts,
n ecessitatin g a m in im u m o th ree biopsies [6 7]. Based on
th e Am erican Academ y o Orth opaedic Su rgeon s criteria
or th e diagn osis o PJI, a positive test is on e th at detects ten
or m ore n eu troph ils in at least ve h igh -pow er elds u sin g
a m icroscope o at least 400 tim es m agn i cation [68 ]. Th e
Am erican Academ y o Orth opaedic Su rgeon s gu idelin es
su ggest th at rozen section m ay be u sed in patien ts su s-
pected o h avin g PJI in w h om th e diagn osis h as n ot been
con rm ed.
Man y orth opedic su rgeon s still believe th at th e presen ce o
pu ru len ce is a m ajor criterion or PJI, alth ou gh patien ts are
n ot o ten diagn osed w ith PJI based on pu ru len ce alon e. Th is
Laboratory test Acute PJI ( < 90 days)
1. ESR No threshold
2. CRP 100 mg/L
3. Synovial WBC count 10,000 cells/L
4. Synovial polymorphonuclear % 90%
5. Leukocyte esterase + or ++
6. Histological analysis of tissue > 5 neutrophils/hpf in 5 hpf (x400 magnification)
Ta b le 10 -3 Thre shold of laboratory value s for the m inor diagnostic crite ria from the Inte rnational Conse nsus Group de nition for
pe riprosthe tic joint infe ction.
Abbre viations: PJI, pe riprosthe tic joint infe ction; ESR, e rythrocyte se dim e ntation rate; CRP, C-re active prote in; WBC, white blood ce ll; hpf, high
powe r e ld.
w as placed in th e m in or criteria category or th e MSIS de -
in ition an d w as rem oved rom th e ICG criteria or PJI, sin ce
th e presen ce o pu ru len ce on ly h as 82% sen sitivity, 32%
speci city, 91% positive predictive valu e, an d 17% n egative
predictive valu e [69]. It is di cu lt to diagn ose PJI based on
a su bjective criterion su ch as pu ru len ce, an d it m ay be
di cu lt to di eren tiate pu ru len ce resu ltin g rom in ection
versu s in f am m atory con dition s su ch as th e m etal-on -m etal
ailu res.
Wh en th e diagn osis o in ection by tradition al m eth ods
proves in e ective, th e u se o seru m an d syn ovial biom ark-
ers m ay aid th e diagn osis o in ection . Seru m biom arkers
th at m ay be u n iqu e to PJI in clu de in terleu kin (IL)-6, tu m or
n ecrosis actor (TNF)- , procalciton in , solu ble in tercellu lar
adh esion m olecu le-1 (sICAM-1), sh ort-ch ain exocellu lar
lipoteich oic acid (sce-LTA), an d m on ocyte ch em oattractan t
protein (MCP)-1 [70 73]. Th ese biom arkers m ay be m ore
speci c th an ESR an d CRP or diagn osin g PJI. Som e o th e
sam e m olecu les m ay be ou n d in th e syn ovial f u id o PJI
cases, in clu din g IL-6 an d TNF- , w h ile addition al cytokin es
su ch as IL-1, IL-8, IL-17, vascu lar en doth elial grow th ac-
tor (VEGF), an d in ter eron (IFN)- m ay be elevated in th e
syn ovial f u id o PJI cases [7476]. Recen t atten tion h as been
placed on oth er syn ovial f u id m arkers, in clu din g -de en sin ,
leu kocyte esterase, syn ovial CRP, cath elicidin LL-37, h u m an
-de en sin -2 (HBD-2), an d HBD-3 [75, 7779]. Wh ile seru m
m ay be easier to obtain th an syn ovial f u id, syn ovial f u id
m arkers m ay be m ore sen sitive an d speci c or th e diagn osis
o PJI.
Chronic PJI ( > 90 days)
30 mm/h
10 mg/L
3,000 cells/L
80%
+ or ++
> 5 neutrophils/hpf in 5 hpf (x400 magnification)
195
 Se ct io n 2Spe cial
situations
10
Infe ction
after
joint
arthroplasty
3 .3 Im a gin g
Im agin g m odalities h ave lim ited u se or diagn osin g PJI (see
ch apter 7 Diagn ostics). All TJA patien ts sh ou ld h ave a plain
x-ray o th e su spected join t, as x-rays in a patien t w ith PJI
m ay be n orm al or dem on strate periosteal bon e grow th ,
tran scortical sin u s tracts, or loosen in g ( Fig 10-3 ). Com pu ted
tom ograph y (CT) an d m agn etic reson an ce im agin g h ave
lim ited u se secon dary to scatter rom th e im plan t, bu t m ay
be u sed to evalu ate th e so t tissu e w ith n din gs su ch as
periprosth etic f u id collection s an d abscesses [80]. Nu clear
im agin g sh ou ld n ot h ave a direct role in th e diagn osis o
PJI, bu t m ay be h elp u l or ru lin g ou t in ection in a ew
cases. Positive em ission tom ograph y labeled w ith f u orode-
oxyglu cose can iden ti y areas o in creased biological activity,
bu t is n ot lim ited to PJI [81, 82]. Patien ts w ith PJI m ay h ave
in creased u ptake on triple-ph ase bon e scan s, bu t scan s m ay
also be positive i th ere is im plan t loosen in g or bon e rem od-
elin g associated w ith n orm al bon e in grow th arou n d th e
im plan t [83]. Wh ite blood cell in diu m scan s or 99m Tc-an ti-
gran u locyte sin gle ph oton em ission com pu ted tom ograph y
(SPECT)/ CT scan s m ay be m ore speci c or PJI, bu t w ill also
sh ow oth er areas o in lam m ation [8 4 8 6 ]. Bon e scan s,
in clu din g WBC-labeled scan s, sh ou ld rarely be ordered
du rin g w orku p o a patien t su spected o PJI as th ey carry
low sen sitivity.
Fig 10 -3 X-ray e vide nce of loose ning se condary to pe riprosthe tic
joint infe ction.
196
4 Tre a t m e n t o p t io n s
Treatm en t o periprosth etic in ection in clu des n on operative
an d operative option s.
Im plan t-related in ection s are ch aracterized by th e presen ce
o bio lm (s)-em bedded bacteria, h en ce th e m ain goal o
an y treatm en t sh ou ld be to com pletely rem ove all bacteria
an d bio lm s adh eren t to th e in ected prosth esis an d th e
su rrou n din g tissu es. Un ortu n ately, th is m ay or m ay n ot be
ach ieved by n on operative m ean s an d m ay explain th e rela-
tively requ en t in ection recu rren ce a ter th e least in vasive
th erapeu tic approach es.
On th e oth er h an d, su rgical treatm en ts are aim ed at ph ysi-
cal rem oval o bio lm s an d in ected tissu es an d im plan ts,
bu t th e best su rgical m odality or treatin g ch ron ic peripros-
th etic join t in ection s rem ain s con troversial, w ith a lack o
con trolled, ran dom ized, com parative stu dies.
Su rgical procedu res ran ge rom sim ple debridem en t w ith
im plan t reten tion or ch an ge o m odu lar im plan t parts to
staged join t reim plan tation , arth rodesis, or am pu tation . On ce
again , available data sh ow th at su ccess is directly related to
th e su rgeon s ability to com pletely rem ove all in ected
m aterials, an d less in vasive su rgical treatm en ts su ch as de-
bridem en t an d reten tion h ave approxim ately h al th e rate
o su ccess, com pared to th ose in volvin g im plan t rem oval.
Com plete rem oval o an in ected im plan t, accu rate debride-
m en t, an d join t recon stru ction can be extrem ely ch allen gin g,
w ith h igh risk o com plication s, n eed or speci cally train ed
team s, an d h igh associated costs. Moreover, th ere is som e
eviden ce th at a less in vasive approach m ay w ork relatively
w ell in oth erw ise h ealth y patien ts an d ail in m ore im m u -
n ocom prom ised h osts.
In som e cases, in w h ich all oth er treatm en ts ailed or w ere
re u sed by th e patien ts, salvage procedu res like resection
arth roplasty, arth rodesis, or am pu tation m ay be th e on ly
possible option .
In spite o grow in g research an d scien ti c eviden ce in th is
eld an d th e m an y e orts to produ ce a u n iversal algorith m
to drive th e m ost appropriate treatm en t in an y given patien t,
treatm en t ch oice still largely relies on each team s experien ce
an d on an open discu ssion w ith th e patien t abou t possible
risk an d ben e ts o di eren t option s accordin g to h is or h er
speci c con dition an d n eeds.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Antonia F Chen, Carlo L Roman, Lorenzo Drago, Javad Parvizi
4 .1 No n s u rgica l t re a t m e n t
Given th e bio lm -related n atu re o PJIs, m edical treatm en ts
are o ten o lim ited valu e an d u n able to ach ieve prolon ged
in ection con trol w h en u sed alon e [87 ]. Th e rate o ailu re
is m arkedly h igh er w h en th e PJI u l lls th e criteria o ch ron -
ic in ection , even w h en patien ts did u n dergo open debride-
m en t w ith ou t im plan t rem oval [88 , 8 9 ].
With th e lack o e ective an tibio lm agen ts or system ic
adm in istration [90 ], n on operative treatm en t m ain ly relies
on sym ptom atic treatm en ts (eg, an tiin f am m atory dru gs,
an algesics, orth opedic brace) an d on su ppressive an tibiotic
th erapy. Su ppressive an tibiotic th erapy is de n ed as th e
prolon ged u se o oral an tibiotics or th e preven tion o re-
lapsin g sym ptom s an d u n ction al ailu re in th ose patien ts
w ith im plan t reten tion .
Non su rgical treatm en t is gen erally reserved or patien ts w ith
a n on pain u l septic prosth esis cau sed by m icroorgan ism s
th at are sen sitive to oral an tibiotics. In particu lar, su ppres-
sive an tibiotic treatm en t m ay be in dicated or patien ts in
w h om on e or m ore o th e ollow in g are presen t [28, 59]:
Re u sal o su rgical treatm en t
Can n ot be su rgically treated becau se o a h igh su rgical
risk du e to com orbidities
Have an in ection th at h as n ot been eradicated a ter
previou s su rgical treatm en t(s), accordin g to clin ical,
laboratory, or im agin g data
Not pain u l an d w ell-osseoin tegrated in ected im plan ts,
in w h ich an in creased disability an d/ or large bon e
de ect secon dary to rem oval o th e prosth esis m ay be
oreseen
Th ere is n o clear eviden ce th at on e an tibiotic regim en is
m ore e ective th an an oth er [28, 59] an d m an y recom m en da-
tion s are largely based on em pirie decision s. Iden ti cation
o th e m icroorgan ism an d selection o th e an tibiotic th erapy
based on th e su sceptibility pattern o th e isolated path ogen ,
pre erably obtain ed rom deep sam ples by join t aspiration
or su rgical debridem en t, is gen erally recom m en ded. Takin g
in to accou n t th e low probability o in ection eradication an d
lim ited scien ti c data available, an tibiotic treatm en t can be
divided in tw o steps:
1. In du ction to rem ission
2. Ch ron ic su ppression
Th e rst step is u su ally ach ieved by u sin g a bactericidal oral
or in traven ou s com bin ation o an tibiotics, in clu din g ri-
am pin , th at sh ou ld n ever be u sed alon e or th e h igh risk
o in du cin g bacterial resistan ce, in cases o gram -positive
in ection , or lu oroqu in olon e in cases o gram -n egative
in ection , w h en ever possible. Th e rst ph ase o an tibiotic
treatm en t sh ou ld be m ain tain ed u n til clin ical sign s o in ec-
tion disappear an d system ic in f am m atory param eters, eg,
CRP or ESR, im prove or 612 w eeks. A ter th is period,
ch ron ic oral an tibiotic su ppression sh ou ld be in itiated u sin g
m on oth erapy or an association o an tibiotics w ith a good
sa ety pro le an d h igh oral bioavailability.
Th e optim al an tibiotic treatm en t du ration h as n ot been
establish ed, bu t it m ay last several m on th s an d o ten depen ds
on clin ical con dition s an d on its tolerability by th e patien t.
Ideally, e ective su ppressive th erapy sh ou ld be adm in istered
or th e rest o th e patien ts li e, bu t th is is rarely observed.
Accordin g to th e literatu re, th e average len gth o oral an ti-
biotic su ppression is approxim ately 2 years, ran gin g rom 4
to 100 m on th s in patien ts w ith ch ron ic PJI w ith a reported
su ccess rate h igh er th an 60% a ter prolon ged ollow -u p
periods [9194]. Oth er au th ors did n ot observe sim ilar resu lts
an d reported a h igh rate o adverse even ts associated w ith
ch ron ic an tibiotic th erapy [95].
Th ere is n o clin ical experien ce abou t th e con sequ en ces o
stoppin g su ppressive an tibiotic treatm en ts an d th e risk o
relapse or in ection dissem in ation an d secon dary sepsis.
Experien ce rom ch ron ic osteom yelitis su ggests th at th ese
in ection s gen erally rem ain localized [96].
4 .2 De b rid e m e n t a n d re t e n t io n
Debridem en t an d im plan t reten tion , also kn own as irrigation
an d debridem en t, aim s at preservin g th e already im plan ted
prosth esis, treatin g th e patien t w ith su rgical clean in g o th e
prosth esis, w ith or w ith ou t ch an gin g m odu lar parts o th e
im plan t, an d debridem en t o th e su rrou n din g tissu es ol-
low ed by an tibiotic treatm en t.
Th ere is a gen eral con sen su s or th e poten tially positive
aspects o an irrigation an d debridem en t procedu re [90, 97]
com pared w ith exch an ge su rgeries: redu ced risk o com pli-
cation s an d blood loss, bon e stock an d u n ction preservation
an d redu ced costs. Still, th e su ccess rates o th is debridem en t
procedu re are low an d variable in th e literatu re, ran gin g
rom 15% to 75% , w ith an average eradication rate o 44.9%
at a m ean 52 m on th s ollow -u p in a recen t system atic review ,
in clu din g periprosth etic kn ee an d h ip in ection s [98].
197
 Se ct io n 2Spe cial
situations
10
Infe ction
after
joint
arthroplasty
In dication s or per orm in g an irrigation an d debridem en t
are n ot w ell de in ed an d ran ge rom th e presen ce o a
w orkin g join t w ith a w ell- xed im plan t to th e du ration o
sym ptom s [99].
I irrigation an d debridem en t is per orm ed, it is im perative
to en su re th at th e prosth eses are w ell- xed, n ot pain u l an d
w ell-position ed an d th ere is a good so t-tissu e en velope to
cover th e prosth esis.
Moreover, th e literatu re su ggests th at irrigation an d debride-
m en t sh ou ld be pre erred over su rgical rem oval o th e exist-
in g im plan t w h en sym ptom s are su cien tly recen t. Sym p-
tom s du ration m ay ran ge rom early, postsu rgical, in ection s
rom 3 to 12 w eeks rom in dex procedu re, an d rom 3 to 4
w eeks or late h em atogen ou s in ection s [97, 100104].
A h igh er su ccess rate or th is procedu re h as been reported
in h ealth ier patien ts an d in in ection s w ith low -viru len ce
organ ism s [89, 105110].
Absolu te con train dication or irrigation an d debridem en t
in clu de th e in ability to close a w ou n d or th e presen ce o a
loose prosth esis. Relative con train dication s are th e presen ce
o a sin u s tract, an in ection w ith h igh ly viru len t organ ism s
su ch as MRSA [1 09, 1 11] or polym icrobial in ection s [11 2],
o ten as a resu lt o th e presen ce o a sin u s, an d in patien ts
w ith exten sive com orbidities, in particu lar th ose w ith im -
m u n ocom prom ised statu s [10 7, 11 3]. Marcu lescu et al [92]
ou n d th at th e presen ce o a sin u s tract leads to an odds
ratio o 2.84 or ailu re o irrigation an d debridem en t.
Con cern in g su rgical tech n iqu e, th ere is a con sen su s [28 , 5 9 ]
th at irrigation an d debridem en t sh ou ld be per orm ed m e-
ticu lou sly an d accordin g to th e ollow in g steps:
1. Preoperative optim ization o th e patien t; irrigation
an d debridem en t sh ou ld n ot be regarded as an
em ergen cy procedu re. Th e patien t, with ou t gen eralized
sepsis, sh ou ld be optim ized prior to th e procedu re.
2. Good visu alization an d th orou gh debridem en t by
open access. Su rgical access sh ou ld pre erably be
obtain ed th rou gh an already existin g scar. En doscopic
or arth roscopic access h as n o role in irrigation an d
debridem en t o an in ected prosth etic join t, sin ce
several stu dies dem on strate th at th e ou tcom e o
irrigation an d debridem en t is m arkedly w orse w h en
debridem en t is per orm ed u sin g arth roscopy [101, 106,
11 4 ].
198
3. Rem oval an d exch an ge o all m odu lar parts o th e
in ected im plan t w h en ever possible. Alth ou gh th ere is
n o clear eviden ce in th e literatu re regardin g th e role
o exch an gin g m odu lar com pon en ts [97] an d th e act
th at th is practice resu lts in added expen ses, prolon gs
th e su rgery, an d cou ld poten tially in crease m orbidity,
it h as also been poin ted ou t th at it can redu ce bacterial
bu rden by rem ovin g m icroorgan ism s adh eren t on th e
rem oved com pon en ts an d it allow s access to parts o
th e join t th at oth erw ise cou ld n ot be reach ed, th u s
im provin g th e debridem en t procedu re.
4. Obtain m u ltiple tissu e-cu ltu re sam ples, pre erably n ot
swabs [115], an d sen d th e rem oved im plan t com pon en ts
or m icrobiological an alysis an d bio lm -disru ptin g
son ication [116, 117] or ch em ical processin g [118]; ou r
to six tissu e sam ples sh ou ld be taken rom areas th at
m acroscopically appear m ost clin ically in ected. Th ese
sh ou ld in clu de th e su per cial, deep, an d periprosth etic
layers an d th e in ter aces between m odu lar com pon en ts.
Th e sam ples sh ou ld be su bm itted or aerobic an d
an aerobic cu ltu re. An tibiotic proph ylaxis at th e tim e
o in du ction does n ot alter th e resu lts o th e m icrobio-
logical cu ltu res obtain ed du rin g th e su rgery an d
sh ou ld n ot be w ith h eld [119].
5. Copiou s join t irrigation w ith approxim ately 69 L o
salin e. Th ere is n o eviden ce th at u sin g an tiseptic
solu tion s provides an y ben e t over salin e. Th e u se o
h igh -pressu re pu lsatile lavage h as recen tly been
sh ow n to be in e ective in dislodgin g bio lm s [120]
an d som e reports su ggested th at it m ay even spread
in ection deeper [121, 122].
6. Rem ove th e prosth esis i loosen ed. Even i preopera-
tive assessm en ts did sh ow th at th e im plan t is w ell
xed, th e prosth esis sh ou ld be tested in traoperatively
or its stability an d osseoin tegration . In th e case th e
im plan t sh ou ld be ou n d loosen ed in traoperatively, it
sh ou ld be rem oved, sh i tin g to a resection arth roplasty
or to a on e- or tw o-stage procedu re. Th is even tu ality
sh ou ld be discu ssed in advan ce w ith th e patien t an d
th e decision an ticipated as part o th e in orm ed
con sen t.
Repeated irrigation an d debridem en t o ers lim ited im prove-
m en t in th e eradication rate at n al ollow -u p [123] an d is
n ot recom m en ded [90] u n less w ith in a speci c protocol an d
w ith adequ ate patien t in orm ation [120]. An in crease in th e
ailu re rate o im plan t revision su rgery, in th e case o in ection
relapse a ter previou s u n su ccess u l irrigation an d debride-
m en t procedu res, h as been sh ow n [12 4 , 1 2 5].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Antonia F Chen, Carlo L Roman, Lorenzo Drago, Javad Parvizi
Irrigation an d debridem en t is u su ally ollow ed by a variable
period o an tibiotic treatm en t, ran gin g rom 4 to 12 w eeks.
An tibiotic treatm en t sh ou ld be adm in istered system ically
an d targeted to th e isolated path ogen (s) w h en ever possible.
Th ere is in su cien t eviden ce to su pport adm in istration o
con tin u ou s in traarticu lar an tibiotics or th e treatm en t o PJI
an d th is is n ot cu rren tly recom m en ded [90, 28].
Sim ilarly, th ere is n o con clu sive eviden ce th at th e u se o
an y local an tibiotic-im pregn ated resorbable m aterial sig-
n i can tly im proves th e ou tcom e o su rgical in terven tion or
irrigation an d debridem en t, alth ou gh th eir u se does n ot
appear to be con train dicated [126, 127].
4 .3 On e - a n d t w o -s t a ge e xch a n ge s
Exch an ge arth roplasty su rgery or in ection , on e- or two-stage
su rgery, is a ch allen gin g procedu re an d sh ou ld be reserved
or experien ced cen ters an d su rgeon s. Th e m orbidity an d
m ortality associated w ith su ch su rgery sh ou ld n ot to be
ign ored. Team w ork is param ou n t to th e su ccess o th e su r-
gery. A m u ltidisciplin ary approach w ith m icrobiologists,
in ectiou s diseases ph ysician s, critical-care an esth esiologist,
plastic su rgeon s, an d orth opedic su rgeon s w ith a particu lar
in terest in in ection is essen tial [39].
Cu rren tly, tw o-stage exch an ge arth roplasty su rgery is th e
m ost popu lar su rgical regim e or th e m an agem en t o PJI in
North Am erica an d in several oth er cou n tries w orldw ide;
h ow ever, to date n o ran dom ized con trolled trial provided
absolu te in dication s or con train dication s or on e- or tw o-
stage exch an ge arth roplasty an d com parative large prospective
stu dies are lackin g [39, 100, 128].
Patien t selection bias, variability in su rgical tech n iqu es,
in clu din g tim e periods prior to reim plan tation or th e u se o
cem en ted or cem en tless im plan ts, w ide di eren ces in th e
reported rates o in ection eradication an d in m orbidity an d
m ortality m ake direct com parison s betw een on e- an d tw o-
stage procedu res particu larly di cu lt [129, 130].
A recen t system atic review exam in ed tw o-stage kn ee ex-
ch an ge in 38 stu dies an d 1,421 patien ts to provide, on average,
a better ou tcom e com pared to on e-stage, as reported in six
papers an d 204 patien ts, ie, 89.8% in ection eradication rate
at a m ean 44.7 m on th s ollow -u p versu s 81.9% at 40.7
m on th s [1 3 1 ]. Sim ilar n din gs w ere reported or th e h ip,
w ith an average in ection eradication rate o 81.7% a ter a
sin gle-stage (20 papers an d 1,221 patien ts, at 58.4 m on th s
m ean ollow -u p) an d 91.1% a ter tw o-stage (63 papers,
3,360 patien ts, 67.3 m on th s ollow -u p) [132]. Con siderin g
a sin gle-stage cem en tless exch an ge (n = 81, on ly th ree stu d-
ies available), th e average in ection eradication rate w as
91.4% at a m ean ollow -u p o 81 m on th s. On th e oth er side,
satis actory resu lts h ave been recen tly reported in selected
patien ts treated w ith partial tw o-stage revision su rgery,
in w h ich on ly on e com pon en t o a h ip prosth esis h ad been
exch an ged in a tw o-stage procedu re [133].
Con cern in g th e sh ou lder prosth esis, a recen t system atic
review revealed n o clear di eren ce in in ection con trol com -
parin g on e- or tw o-stage revision su rgery, w ith an average
better u n ction al resu lts in patien ts treated w ith a on e-stage
procedu re [134].
Alth ou gh de n itive in dication s an d con train dication s to
on e- or tw o-stage exch an ge are lackin g, th ere is som e con -
sen su s [28, 90] th at on e-stage exch an ge can be a reason able
option or th e treatm en t o PJI in circu m stan ces w h ere
e ective an tibiotics are available bu t n ot in patien ts w ith
system ic m an i estation s o in ection , ie, sepsis, in w h om
resection arth roplasty an d redu ction o biobu rden m ay be
n ecessary. Relative con train dication s to per orm in g a on e-
stage exch an ge m ay in clu de lack o iden ti ication o an
organ ism preoperatively or th e presen ce o m u lti-resistan t
bacteria, th e presen ce o a sin u s tract or severe so t-tissu e
in volvem en t th at m ay lead to th e n eed or f ap coverage [28,
135].
Th e im m u n ocom prom ised patien t or th e presen ce o m edical
com orbidities, in clu din g obesity, m etastatic disease, advan ced
cardiac disease, an d ren al an d/ or liver dys u n ction ( Fig 10 -4 ),
h ave been sh ow n to im pact on th e in ection eradication
su ccess rates an d certain ly in f u en ce m orbidity an d m ortal-
ity. Th e presen ce o com orbidities m ay redu ce th e su ccess
rate o on e-stage revision , th u s represen tin g a relative con -
train dication to th is su rgical option [137].
Con dition s in w h ich on e-stage is con sidered to be con train -
dicated can be m an aged th rou gh a two-stage approach . Th ese
in clu de:
Patien ts w ith system ic m an i estation s o in ection
(ie, sepsis)
In ection appears obviou s bu t n o organ ism h as been
iden ti ed preoperatively or preoperative cu ltu res
iden ti ed are di cu lt-to-treat an d an tibiotic-resistan t
organ ism s
Presen ce o a sin u s tract or in adequ ate an d n on viable
so t-tissu e coverage
199
 Se ct io n 2Spe cial
situations
10
Infe ction
after
joint
arthroplasty

a b c d

e f

g h i
Fig 10 -4 a i A 5 0 -ye ar-old wom an with re nal transplant. Afte r six pre vious hip surge rie s, she cam e with a chronic pe riprosthe tic
hip infe ction with draining sinus and se ve re bone loss. Culture s gre w out m ultire sistant Esche re chia coli and Pse udom ona s
a e ruginosa.
a b Pre ope rative x-rays.
cd Afte r se ptic prosthe sis and ce m e nt re m oval and pre form e d hip space r im plant.
e At the tim e of space r re m oval. Note the large bone de fe ct of the proxim al third of the fe m ur.
f Intraope rative ace tabulum re construction with m orce llize d bone grafts and unce m e nte d prosthe sis.
g i Postope rative x-rays 2 ye ars afte r re im plantation. Note bone re m ode ling both at the fe m oral and ace tabular site s.

200 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Antonia F Chen, Carlo L Roman, Lorenzo Drago, Javad Parvizi
Con cern in g tw o-stage exch an ge, th ere is n o de n itive evi-
den ce in th e literatu re as to th e spacer ch oice or optim al
tim e in terval betw een th e tw o stages: reports vary rom 2
w eeks to several m on th s [39, 127, 128, 132]. Videos dem on -
stratin g tech n iqu es on proper spacer abrication or h ip
( Vid e o 10 -1 , Vid e o 10 -2 ), kn ee ( Vid e o 10 -3 ), an d sh ou lder
( Vid e o 10-4 ) can be view ed. In traven ou s an tibiotic th erapy
lastin g 46 w eeks w ith su bsequ en t cessation o an tibiotics
or 28 w eeks prior to reim plan tation is m ost com m on ly
em ployed.
Th ere is also n o de n itive eviden ce con cern in g econ om ic
im pact o on e- versu s tw o-stage revision ; di eren ces in cost
betw een on e-stage an d tw o-stage exch an ge arth roplasty are
n ot straigh t orw ard to an alyze. Costs m ay vary du e to ac-
tors associated w ith h ospital acilities, patien ts, su rgeon s,
an d th e in ectin g organ ism . How ever, it m ay gen erally be
accepted th at patien t m orbidity, operative tim e, operatin g
Vid e o 10-1 The making a hip space r vide o de m onstrate s a m e thod
for cre ating an articulating antibiotic hip space r to re place an infe cte d
hip re place me nt.
Vid e o 10-3 The m aking an articulating kne e space r vide o
de m onstrate s a way to cre ate an antibiotic ce m e nt space r to m anage
an infe cte d total kne e re place m e nt. Although the re are a num be r of
ways to cre ate such a space r, this particular m e thod is a re asonable
option to do so.
room u se, h ospital an d su rgeon ees, an d du ration o an ti-
biotic adm in istration are less w h en u n dergoin g on e proce-
du re versu s a m in im u m o tw o m ajor procedu res. A cost
an alysis by Klou ch e et al [1 3 7 ] revealed th at tw o-stage
revision o septic total h ip arth roplasty cost 1.7 tim es m ore
th an a on e-stage revision . I th e resu lts o on e-stage an d
tw o-stage exch an ge arth roplasty are com parable, on e-stage
m ay be pre erred du e to th e advan tages o decreased patien t
m orbidity, low er cost, im proved m ech an ical stability o th e
a ected lim b, an d sh orter period o disability [138].
4 .4 Sa lva ge p ro ce d u re s a n d a m p u t a t io n
Salvage procedu res or periprosth etic in ection s in clu de
resection arth roplasty or perm an en t spacer an d arth rodesis.
Resection h ip arth roplasty can be very su ccess u l in th e
con trol o in ection an d allow or assisted am bu lation ,
alth ou gh u n ction al ou tcom e is o ten rath er poor [139].
Vid e o 10-2 The coating a fe m oral ste m vide o de m onstrate s a
m e thod for cre ating an articulating antibiotic hip space r to re place an
infe cte d hip re place m e nt.
Vid e o 10-4 The making a shoulde r space r vide o de m onstrate s
cre ation of an antibiotic articulating space r for managing an infe cte d
shoulde r re place m e nt.
201
 Se ct io n 2Spe cial
situations
10
Infe ction
after
joint
arthroplasty

Sim ilarly, resection arth roplasty or th e perm an en t u se o 4 .5 Tre a t m e n t a lgo rit h m

an articu latin g spacer h ave been described as possible op- Several classi cation s o PJIs h ave been proposed in th e last
tion s to m an age periprosth etic sh ou lder in ection w ith h igh ew decades, aim ed at drivin g treatm en t ch oice [38, 42, 154
su ccess rate on in ection con trol, bu t w ith relatively poor 156]; h ow ever, n o sin gle algorith m is u n iversally recogn ized
u n ction al resu lts [133]. an d accepted in th e clin ical u se [28, 90].

Kn ee arth rodesis or a xed kn ee prosth esis m ay be appropri-
ate option s or patien ts w h o h ave h ad ailed m u ltiple attem pts
at recon stru ction an d stan d an u n acceptably h igh risk o
recu rren t in ection w ith repeat arth roplasty procedu res an d/
or h ave a de cien t exten sor m ech an ism or in adequ ate so t-
tissu e coverage, exten sive bon e loss, an d a pain u l an d/ or
u n stable join t [126, 135, 140144].
Treatm en t algorith m s, based on variou s periprosth etic
in ection classi cation s, are m ain ly ocu sed on th e tim e o
on set o th e in ection ; th is probably relies on th e im plicit as-
su m ption th at th e sh orter th e tim e rom on set o an in ection ,
th e less th e spreadin g o bacterial colon ization an d h en ce
th e h igh er th e ch an ce to save an im plan t by a less in vasive
su rgical approach , like debridem en t an d reten tion .

Severely im m u n ocom prom ised h osts, alcoh ol, or in traven ou s
dru g abu sers, an d/ or th e presen ce o polym icrobial in ec-
tion s or th ose du e to h igh ly resistan t organ ism s or w h ich
th ere is n o e ective an tim icrobial th erapy m ay also ben e t
rom kn ee arth rodesis [145, 146].
Relative con train dication s m igh t apply to n on am bu latory
patien ts or th ose w ith exten sive m edical com orbidity th at
preclu des m u ltiple su rgeries. In act, kn ee arth rodesis m ay
be per orm ed as on e- or tw o-stage, th e decision depen din g
on th e in dividu al circu m stan ces an d th e h ost actors. On e-
stage arth rodesis, u sin g an extern al xation device, is m ost
su ccess u l w h en con du cted in cases o PJI cau sed by low -
viru len ce organ ism s an d m in im al so t-tissu e com prom ise
To th e au th ors kn ow ledge, th e algorith m th at h as been
exten sively tested an d validated clin ically, by th e sam e au -
th ors th at h ave developed th e protocol, is th e on e proposed
by Zim m erli et al [89, 1 57, 1 58]. Th is algorith m , w ith on ly
sligh t m odi cation s, h as been recen tly in clu ded in th e In ec-
tiou s Diseases Society o Am erica gu idelin es [160]; it relies
on th e tim e rom on set o in ection an d on som e oth er vari-
ables, to progressively drive decision s rom th e least in vasive
debridem en t an d reten tion ( Ta b le 10 -4 ) to prosth esis exch an ge
( Ta b le 10-5 , Ta b le 10 -6 ), or to oth er option s ( Ta b le 10 -7 ).
Presentation Observation Action

[147]. Eradication o in ection prior to arth rodesis allow s an Duration of symptoms Yes Well-fixed prosthesis No Removal of
< 3 weeks OR Absence of sinus tract prosthesis
expan ded arm am en tariu m or xation , su ch as th e u se o Joint age < 30 days Susceptible to oral
Yes Debridement
in tram edu llary an d platin g devices, w ith a reported su ccess antimicrobial agents
and retention
rate in in ection con trol exceedin g 90% [135, 148, 149].
No Removal of
prosthesis
Th e ch oice betw een arth rodesis an d am pu tation n eeds to
take in to accou n t th e clin ical situ ation o th e in dividu al an d Ta b le 10 -4 Tre atm e nt algorithm to de cide de bride m e nt and
re te ntion, re writte n and according to Infe ctious Dise ase s Socie ty of
patien t pre eren ce.
Am e rica guide line s [15 4 ].

Am pu tation or treatm en t o PJI a ectin g th e kn ee or th e

h ip m ay be appropriate in selected cases in volvin g a n on - Presentation Action

am bu latory patien t, n ecrotizin g asciitis resistan t to aggres-

sive debridem en t, extrem ely severe bon e loss, or com plex THA One-stage
periprosth etic in ected ractu res, in adequ ate so t-tissu e Good soft tissue exchange
coverage, m u ltiple ailed attem pts at staged exch an ge an d Identity of the organisms determined preoperatively
Good bone stock
resection arth roplasty or severe periph eral vascu lar disease, Susceptible to oral agents with high oral bioavailability
n eu rovascu lar in ju ry, an d pain [132, 136, 150, 151]. Except in Use of antibiotics-impregnated bone cement for fixation
em ergen cy cases, re erral to a cen ter with specialist experien ce No bone grafting required

in th e m an agem en t o PJI is advised be ore am pu tation is

Ta b le 10 -5 Tre atm e nt algorithm to de cide one -stage e xchange ,
carried ou t, du e to h igh m ortality rates [146, 152, 153]. re writte n and according to Infe ctious Dise ase s Socie ty of Am e rica
guide line s [15 4].
Abbre viation: THA, total hip arthroplasty.

202 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Antonia F Chen, Carlo L Roman, Lorenzo Drago, Javad Parvizi

Am on g several lim itation s th at can be ou n d in th is or oth er
treatm en t algorith m s, th e qu estion able role o tim e rom
in ection on set is w orth n otin g. Alth ou gh th e assu m ption
th at an im plan t-related in ection is a tim e-depen den t process
looks in tu itive, as it is o ten th e case or paren ch ym al organ s,
cu rren tly available data on bio lm orm ation con tradict th e
sim ple equ ation early in ection = less in vasive approach
an d better progn osis, su ggestin g th at tim e m ay n ot be th e
(on ly) reliable param eter to predict th e su ccess o im plan t
reten tion . In act, th ere is in creasin g eviden ce th at m atu re
bio lm (s) are orm ed w ith in a ew h ou rs or days a ter bac-
terial adh esion . Th is in din g m ay explain w h y im plan t
reten tion o ten ails, even i per orm ed w ith in days or w eeks
a ter su rgery an d it raises im portan t qu estion s su ch as
w h eth er th e tim e lim its o 3 w eeks, 30 days, or 90 days are
based on a scien ti cally sou n d ration ale or on ly on an in su -
cien t u n derstan din g o th e bio lm -related in ection s.
In th is regard it sh ou ld also be n oted th at cu rren tly available
classi cation s an d treatm en t algorith m s o periprosth etic
in ection do n ot con sider an oth er variable th at m ay be at
least as im portan t as tim e to drive th e ch oice an d th e su ccess
o a given su rgical treatm en t: th e localization o bacteria
arou n d th e im plan t. Th e site o bacterial colon ization m ay
in act be su ch th at it is n ot tech n ically possible to rem ove
th e colon izin g m icroorgan ism s even i debridem en t is per-
orm ed at a very early stage o in ection on set. In act, even
a ew bacteria adh erin g to th e im plan t-bon e in ter ace m ay
n ot be reach ed by su rgical debridem en t w ith im plan t reten -
tion , th u s m ain tain in g th e in ection , wh ich m ay even tu ally
recu r a ter w eeks or m on th s a ter su rgical debridem en t.
Cu rren t classi cation s an d treatm en t algorith m s probably
om it localization o bio lm an d bacteria as a key actor to
th e su ccess o su rgery sim ply becau se w e do n ot h ave ap-
propriate tech n iqu es to dem on strate th em prior to or du rin g
su rgery.
Moreover, th ere is grow in g eviden ce th at ou r tech n ical
ability to dislodge establish ed bio ilm s rom a su r ace is
particu larly lim ited, as, or exam ple, sim ple scrapin g or
cu rettage m ay on ly be partially e ective as revealed by
electron -scan im ages, w h ile pu lse lavage h as been recen tly
reported to be in e ective [16 0], th u s u rth er lim itin g th e
e cacy o an y less in vasive approach .

Presentation Action
Poor soft tissue OR Yes Two-stage
Difficult to treat microorganisms, AND exchange
No prior two-stage exchange for infection or prior two-
stage exchange and reason for failure, AND No See
Delayed reimplantation technically feasible, AND Ta ble 10 -7
Anticipated good functional outcome

Ta b le 10 -6 Tre atm e nt algorithm to de cide two -stage e xchange ,

re writte n and according to Infe ctious Dise ase s Socie ty of Am e rica
guide line s [15 4].

Presentation Observation Action

Necrotizing fasciitis OR No Patient No Resection

Severe bone loss OR comorbidities OR arthroplasty OR
Inability or failure of soft- Patients Arthrodesis
tissue coverage OR preferences Yes Medical therapy
Prior failed attempt of preclude additional only
resection arthroplasty surgery
or arthrodesis to control
infection OR Yes Consider
No medical therapy available amputation
OR Referral to
Functional benefit to specialty hospital
amputation over resection
arthroplasty or arthrodesis

Ta b le 10 -7 Tre atm e nt algorithm to de cide othe r options, re writte n

and according to Infe ctious Dise ase s Socie ty of Am e rica guide line s
[15 4 ].

203
 Se ct io n 2Spe cial
situations
10
Infe ction
after
joint
arthroplasty

An oth er im portan t variable th at m ost o th e cu rren t algo- Presentation Type o Average

treatment in ection
rith m s do n ot con sider is th e h osts type. Th e stu dy o Sim p- eradication rate
son et al [1 61, 1 62] ou n d th at a less in vasive approach to Patients who refuse surgical treatment Less invasive Variable, but up
bon e in ection m ay w ork in Ciern y-Mader type A, im m u - OR treatment (ie, to 60% in some
n ocom peten t h osts, bu t n ot in type B or C patien ts. Also, Patients who cannot be surgically treated because of prolonged reports
a high surgical risk due to comorbidities suppressive
cu rren tly available classi cation s o h osts type look largely AND antibiotic
based on em piric observation an d n ot on scien ti c data, Patients who have an infection that has not been treatment)
w ith su bstan tial di eren ces betw een scorin g system s [3 8, eradicated according to clinical, laboratory, or
imaging data
15 2, 1 53 ]. Little is tru ly kn ow n abou t th e h osts im m u n e
AND
system at th e presen t tim e. Patients who have an infection caused by pathogens
sensitive to oral antibiotics
AND
Based on th ese con sideration s, th e au th ors n d it m ore ap- Not painful and well-osteointegrated infected
propriate to provide a pro le o possible can didates to th e implants
variou s treatm en t strategies based on cu rren t kn ow ledge OR
In which an increased disability and/or large bone
an d w ith th e relative ch an ce o in ection eradication rate defect secondary to removal of the prosthesis may
( Ta b le 10-8 , Ta b le 10-9 , Ta b le 10-10 ). be foreseen
Short symptoms duration ( < 412 weeks from Debridement 1575%
Th is sch em a, alth ou gh n ecessarily in com plete an d su bject index procedure or < 4 weeks from first diagnosis and implant (both for hip or
for late hematogenous infections) retention knee)
to u rth er u pdate as n ew data w ill becom e available, m ay OR (irrigation and
serve as a basis to discu ss risk an d ben e ts o di eren t treat- Patients who refuse surgical removal of the existing debridement) On average
m en t option s in an y given patien t. implant approximately
OR 45% at 50
Patients who cannot be treated with implant months follow-up
removal because of a high surgical risk due to
comorbidities
AND
Not painful and well-osteointegrated infected
implants, with good soft-tissue envelope to cover
the prosthesis
AND/OR
In which an increased disability and/or large bone
defect secondary to removal of the prosthesis may
be foreseen
AND/OR
Type Ahosts
AND/OR
Low-virulence organisms
AND/OR
No sinus tracts

Ta b le 10 -8 Propose d patie nts pro le for im plant re te ntion in

pe riprosthe tic hip or kne e infe ctions.

204 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Antonia F Chen, Carlo L Roman, Lorenzo Drago, Javad Parvizi

Presentation Type o Average Presentation Type o Average

treatment in ection treatment in ection
eradication rate eradication rate
Longer symptom duration ( > 412 weeks from index One-stage 57100% Periprosthetic chronic joint infection Arthrodesis > 90%
procedure or > 4 weeks from first diagnosis for late exchange (hip) and from AND/OR or fixed
hematogenous infections 73100% (knee) Failed multiple attempts at reconstruction joint
OR AND/OR prosthesis
Periprosthetic chronic joint infection On average Apainful and/or unstable joint (knee)
OR approximately AND/OR
Painful or loosened infected implants, with good soft- 80% at 60 Unacceptably high risk of recurrent infection
tissue envelope to cover the prosthesis months follow-up AND/OR
AND/OR With a deficient extensor mechanism
Type Ahosts AND/OR
AND/OR Inadequate soft-tissue coverage
Low-virulence organisms AND/OR
AND/OR Extensive bone loss
No sinus tracts AND/OR
Longer symptoms duration ( > 412 weeks from index Two-stage 74100% (both Severely immunocompromised hosts, alcohol,
procedure or > 4 weeks from first diagnosis for late exchange for hip or knee) or drug abusers
hematogenous infections AND/OR
OR On average Polymicrobial infections or due to highly-resistant
Periprosthetic chronic joint infection approximately organisms for which there is no effective antimicrobial
OR 90% at 60 therapy
Painful or loosened infected implants, with good soft- months follow-up Periprosthetic chronic joint infection Resection > 90%
tissue envelope to cover the prosthesis AND/OR arthroplasty
AND/OR Failed multiple attempts at reconstruction (hip)
All microorganism types or unidentified pathogen AND/OR
AND/OR Apainful and/or unstable joint
Presence of a sinus tract or inadequate and nonviable AND/OR
soft-tissue coverage Unacceptably high risk of recurrent infection
AND/OR AND/OR
Generalized sepsis Inadequate soft-tissue coverage
AND/OR
Ta b le 10 -9 Propose d patie nts pro le for hip or kne e e xchange Extensive bone loss
proce dure s. AND/OR
Severely immunocompromised hosts, alcohol,
or drug abusers
AND/OR
Polymicrobial infections or due to highly resistant
organisms for which there is no effective antimicrobial
therapy
Failure, refusal, or contraindications to other salvage Amputation
procedures
OR
Necrotizing fasciitis resistant to aggressive
debridement
AND/OR
Severe bone loss that precludes arthrodesis (knee)
AND/OR
Inadequate soft-tissue coverage
AND/OR
Periprosthetic fracture
AND/OR
Peripheral vascular disease and neurovascular injury
or neuropathy

Ta b le 10 -10 Propose d patie nts pro le for hip or kne e salvage

proce dure s or am putation.

205
 Se ct io n 2Spe cial
situations
10
Infe ction
after
joint
arthroplasty

5 Co n clu s io n

Periprosth etic in ection is a ch allen gin g con dition , w h ich

requ ires prom pt recogn ition , accu rate diagn ostic evalu ation ,
an d adequ ate treatm en t.

Given th e cen tral role played by bio lm s, both th e m icro-

biological an d su rgical approach es sh ou ld be speci cally
directed to iden ti y bio lm -em bedded bacteria, preven t
bacterial adh eren ce on im plan t su r ace, an d dislodge bac-
teria an d bio lm s, w h en im plan t su r ace becom e colon ized
by m icroorgan ism s.

Un ortu n ately ou r kn ow ledge o th e path ogen esis o th e

in ection is lim ited an d h en ce m ost cu rren t diagn ostic an d
treatm en t approach es rem ain in adequ ate or on ly partially
e ective.
Fig 10 -5 Microbiological diagnosis can
Moreover, w e still h ave a lack o u n derstan din g o th e h osts be im prove d by close d syste m s that allow
role an d very ew w ays to im prove th e ability o a com pro- colle ction, transportation, and proce ssing
m ised h ost to resist bio lm -related in ection s. of re trie ve d im plants and tissue s. The
MicroDTTe ct syste m fre e s bio lm -e m be dde d
bacte ria e ve ntually pre se nt on a sam ple by
In spite o th ese lim itation s, recen t n ew tech n ologies, m ore
using dithiothre itol, a che m ical com pound
stan dardized treatm en t protocols, an d dedicated cen ters an d able to de stroy bacte rial bio lm s, without
team s h ave raised th e overall in ection eradication rate affe cting pathoge n vitality [118 ].
a ter PJI to approxim ately 8090% , w ith acceptable u n ction
restoration in m ost o th e cases. Based on cu rren t research ,
it m ay be an ticipated th at ou r ability to im prove early diag-
n osis, preven t, an d treat im plan t-related in ection w ill im -
prove in th e u tu re, w h en speci cally design ed diagn ostic
tools ( Fig 10 -5 ), an tibacterial im plan t coatin gs ( Fig 10-6 ), an d
an tibio lm agen ts becom e available.

A u n iversal algorith m to select th e appropriate clin ical decision

or a given patien t is n ot yet available. Th e treatm en t ch oice
sh ou ld still rely on each team s experien ce, open -m in ded
approach , an d ran k discu ssion w ith th e patien t abou t
possible risks an d ben e ts o di eren t option s, accordin g to
speci c con dition s an d n eeds.

206 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Antonia F Chen, Carlo L Roman, Lorenzo Drago, Javad Parvizi

a b

c d

e f
Fig 10 -6a f An 87-ye ar-old cardiopathic m an. Chronic pe riprosthe tic hip infe ction with
draining sinus. Culture s gre w out m ultire sistant Sta phylococcus e pide rm idis.
a Pre ope rative x-ray.
b Clinical aspe ct at the tim e of surge ry.
cd Coating of the ce m e ntle ss im plant with a fast-re sorbable vancom ycin-loade d
hydroge l and one -stage e xchange .
e f X-ray take n 2 ye ars afte r im plantation. The patie nt is fre e of sym ptom s.

207
 Se ct io n 2Spe cial
situations
10
Infe ction
after
joint
arthroplasty
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136. Wo lf M, Cla r H, Frie s e n b ich le r J.
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137. Klo u ch e S, Sa ria li E, Ma m o u d y P. Total
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138. De Ma n FH, Se n d i P, Zim m e rli W, e t a l.
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139. Ca b rit a HB, Cro ci AT, Ca m a rgo OP, e t
a l. Prospective stu dy o th e treatm en t
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cem en t spacer. Clinics (Sao Paulo). 2007
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Per iprosth etic in ection du e to
resistan t staph ylococci: seriou s
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10
Infe ction
after
joint
arthroplasty
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142. Be jo n P, Be re n d t A, At kin s BL, e t a l.
Two-stage revision or prosth etic join t
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th e role o reim plan tation
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143. Ra n d JA, Br ya n RS, Ch a o EY. Failed
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14 4. Sca rp o n i S, Dra go L, Ro m a n D, e t a l.
Cem en tless m odu lar in tram edu llar y
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salvage procedu re in ch ron ically
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lon g-term resu lts. Int Orthop. 2014
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145. Da m ro n TA, McBe a t h AA. Arth rodesis
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m u lticen ter in vestigation o 91 cases.
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Cem en tless m odu lar in tram edu llary
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150. Is ik la r ZU, La n d o n GC, Tu llo s HS.
Am pu tation a ter ailed total k n ee
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151. Sie rra RJ, Tro u s d a le RT, Pa gn a n o MW.
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152. Fe d o rka CJ, Ch e n AF, McGa rr y WM, e t
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158. La ffe r RR, Gra b e r P, Och s n e r PE, e t a l.
Ou tcom e o prosth etic k n ee-associated
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159. Os m o n DR, Be rb a ri EF, Be re n d t AR,
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160. Uris h KL, De m u t h PW, Cra ft DW, e t a l.
Pu lse lavage is in adequ ate at rem oval
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Ste phe n L Kate s, Olivie r Bore ns
Anna Conen, Olivier Borens
11.1 Se p tic a rth ritis
An na Co ne n , Olivie r Bo re ns
1 Ba s ics
Acu te septic arth ritis re ers to bacterial, or rarely, u n gal
in ection s o a join t. It is a m edical an d su rgical em ergen cy
becau se o th e rapid destru ction o th e join t ( Fig 11.1-1 ).
Im m ediate th erapeu tic in terven tion is n ecessary to decrease
th e associated m orbidity an d m ortality. A delay betw een
sym ptom on set an d in itiation o adequ ate th erapy is th e
m ajor determ in an t o poor ou tcom e.
1.1 Et io lo g y
In n ative join ts, septic arth ritis is com m on ly cau sed by
h em atogen ou s seedin g o m icroorgan ism s rom a distan t
in ection ocu s [1 4 ]. Becau se th e syn ovial m em bran e is
h igh ly vascu larized an d con tain s n o lim itin g basem en t m em -
bran e, m icroorgan ism s can qu ickly pass rom th e blood in to
th e join t space resu ltin g in an acu te on set o pu ru len t join t
in f am m ation . Patien ts at h igh risk or h em atogen ou s seedin g
are in traven ou s (IV) dru g u sers, patien ts w ith in dw ellin g
a b
Fig 11.1-1a c Rapid joint de struction in a 21-ye ar-old athle te afte r m istre ate d se ptic arthritis with
m e thicillin-susce ptible Sta phylococcus a ure us (3 m onths be twe e n rst and last x-rays).
vascu lar cath eters, patien ts w ith in ective en docarditis, im -
m u n ocom prom ised h osts, an d elderly people [5, 6]. Oth er
path om ech an ism s in th e em ergen ce o septic arth ritis are
direct in ocu lation o m icroorgan ism s in to th e join t as a
resu lt o in traarticu lar in jection s, su rgical in terven tion s,
open join t in ju ry, or trau m a [7, 8]. Rarely, m icroorgan ism s
en ter th e join t space by spread rom a con tigu ou s ocu s,
su ch as cellu litis, bu rsitis, or osteom yelitis.
Microorgan ism s in th e join t space trigger an acu te syn ovial
in lam m atory respon se. With in a ew h ou rs, activated
in f am m atory cells ll th e closed syn ovial space. Th e in f am -
m atory cells release en zym es an d cytokin es an d th e
m icroorgan ism s produ ce in addition toxin s th at can kill
eu karyotic cells. Th e con sequ en ces are ch em ical toxic dam -
age o th e cartilage an d u n derlyin g su bch on dral bon e bu t
also pressu re dam age du e to th e in creased join t pressu re
du e to th e large accu m u lated in f am m atory e u sion [3, 9].
c
213
 Se ct io n 2Spe cial
situations
11.1Se ptic
arthritis
1.2 In cid e n ce
Septic arth ritis is diagn osed in 2 to 10 person s per 100,000
people per year an d in 5 to 10 patien ts per 10,000 patien ts
h ospitalized in an acu te care acility per year. Th e in ciden ce
is con siderably h igh er in patien ts su erin g rom rh eu m atoid
arth ritis, ie, 28 to 38 patien ts per 100,000 patien ts w ith
rh eu m atoid arth ritis per year. Th e in ciden ce is in creasin g
in recen t years n ot on ly becau se o th e agin g popu lation
an d th e in creasin g u se o im m u n osu ppressive treatm en ts
an d in dw ellin g vascu lar cath eters, bu t also becau se o th e
grow in g n u m bers o join t in terven tion s [3]. Overall, th e risk
o postin terven tion al septic arth ritis is sm all. For join t
in ltration s it relates to 1 case per 22,000 in terven tion s/
in ltration s an d or arth roscopy to 1 case per 2501,000
in terven tion s, respectively [4, 10].
1.3 Ris k fa ct o rs
Most patien ts w h o develop septic arth ritis h ave at least on e
risk actor. Each actor h as a m odest im pact on th e risk o
septic arth ritis, bu t in com bin ation th ey can su bstan tially
in crease th e risk [5, 11]. Th e m ost im portan t risk actor is
preexistin g arth ropath y, su ch as degen erative an d ch ron ic
in f am m atory join t diseases [4 , 8 ]. Older age (> 80 years),
com orbidities in clu din g diabetes m ellitu s, cu tan eou s u lcers,
alcoh olism , an d im m u n osu ppression are also associated w ith
an in creased risk or septic arth ritis [12]. Diseases w ith an
in creased risk or bacterem ia, su ch as IV dru g u se an d in ective
en docarditis, are oth er im portan t risk actors, as is th e skin
colon ization w ith Staphylococcus aureus. Fu rth erm ore, th e
presen ce o distan t in ection oci w ith th e possibility o
secon dary bacterem ia in creases th e risk or septic arth ritis,
in clu din g skin , u rogen ital, gastroin testin al, an d pu lm on ary
in ection s. Overall, th e risk or septic arth ritis a ter a join t
in terven tion is low as m en tion ed above, ie, < 0.01% a ter
syn ovial f u id aspiration an d 0.010.4% a ter arth roscopy.
In traarticu lar steroid in jection s u rth er in crease th e risk,
especially i associated w ith arth roscopy, w h ere th e risk is
27.4 tim es h igh er th an w ith ou t th e adm in istration o steroids
[13, 14].
214
1.4 Lo ca t io n o f in vo lve d jo in t s
In 90% o patien ts w ith septic arth ritis on ly on e join t is
in volved (m on oarth ritis), an d 10% su er rom m u ltiple
join t in volvem en t (oligoarth ritis). Oligoarth ritis is m ain ly
ou n d in patien ts w ith u n derlyin g rh eu m atoid arth ritis [15].
Predom in an tly w eigh t-bearin g join ts are a ected, su ch as
kn ee join ts in 4555% an d h ip join ts in 1525% , ollow ed
by sh ou lder, w rist, an kle, an d elbow join ts (togeth er in
510% ) [4 , 1 6]. Rarely sacroiliac or stern oclavicu lar join ts
an d th e sym ph ysis pu bis are in ected an d in ection is m ore
prevalen t in IV dru g u sers (sacroiliac or stern oclavicu lar
join ts an d sym ph ysis) an d a ter gyn ecological an d u rologi-
cal in terven tion s (sacroiliac join t an d sym ph ysis) [1 7 , 1 8 ].
In ch ildren th e h ip join t is m ost com m on ly a ected in 60% ,
ollow ed by th e kn ee join t in 35% .
1.5 Wh ich m icro b e s ca u s e s e p t ic a r t h rit is?
Overall, S aureus is th e predom in an t cau sative m icroorgan ism
in 4060% , ollow ed by streptococci in 2030% [1, 2, 9, 19,
2 0 ]. Meth icillin -resistan t S aureus h as to be con sidered in
cou n tries w ith a h igh prevalen ce o m eth icillin -resistan ce
[21]. Gram -n egative bacilli are ou n d in 420% , especially
in IV dru g u sers, im m u n ocom prom ised h osts, elderly pa-
tien ts, or a ter trau m a [9]. Cu ltu re-n egative septic arth ritis
cases are described in 1020% as a con sequ en ce o an tim i-
crobial pretreatm en t or astidiou s to grow m icroorgan ism s.
Polym icrobial in ection s are rare (m axim u m o 8% ) an d
o ten associated w ith pen etratin g trau m a.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Anna Conen, Olivier Borens

Depen din g on th e clin ical con text an d th e presen ce o risk
actors, on e can an ticipate th e cau sative m icroorgan ism in
septic arth ritis. Th ere ore, th e m edical h istory is an essen tial
elem en t in n arrow in g th e m icrobiological di eren tial diag-
n osis ( Ta b le 11.1-1 ). In patien ts w ith ou t an y risk actor or
septic arth ritis, or in patien ts w ith diabetes m ellitu s or rh eu -
m atoid arth ritis S aureus is th e predom in an t cau se. In IV
dru g u sers S aureus is th e m ost com m on m icroorgan ism as
w ell, bu t also Pseudomonas aeruginosa (becau se o tap w ater
u se to w ash syrin ge), grou p A streptococci (becau se o a
con com itan t septic ph lebitis) an d Candida species (spp.)
(becau se o con tam in ated lem on ju ice u sed or dru g solu tion )
h ave to be con sidered. Cat or dog bites u su ally resu lt in
in ection s w ith Pasteurella multocida an d Capnocytophaga
canimorsus, rat bites in in ection s w ith Streptobacillus monili-
ormis an d h u m an bites in in ection s w ith m icroorgan ism s
o th e oral cavity su ch as th e HACEK grou p (Haemophilus
spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium
hominis, Eikenella corrodens, an d Kingella kingae) or an aerobes.
A ter join t in ltration or su rgical in terven tion , m icroorgan ism s
o th e skin f ora, in clu din g S aureus an d coagu lase-n egative
staph ylococci, sh ou ld be con sidered. In ch ildren you n ger
th an 2 years o age predom in an tly Kingella kingae is ou n d.
I th ere is a sexu al risk beh avior, gon ococci h ave to be
con sidered, especially i th ere is a con com itan t m acu lar
exan th em a an d polyarticu lar in volvem en t [22 ]. A ter gyn e-
cological in terven tion s (eg, cu rettage or ch ildbirth ) an d
m ain ly in patien ts with im paired h u m oral im m u n e u n ction
Mycoplasma hominis can be ou n d. Brucella spp. sh ou ld be
con sidered in patien ts w h o visited th e Mediterran ean areas
or in case o th e con su m ption o u n pasteu rized m ilk prod-
u cts. Special cu ltu re m edia an d serology are requ ired or
diagn osis. I th e patien t h istory in dicates oligoarth ritis in
com bin ation with gastroin testin al sym ptom s an d m esen teric
lym ph aden opath y, on e sh ou ld also be aw are o Tropheryma
whipplei. Borrelia spp. (ie, Lym e arth ritis) sh ou ld be con -
sidered in case o an oligoarticu lar in volvem en t an d a ter
a stay in an en dem ic area, even i n o tick bite w as recogn ized.

Microorganism Clinical clues/risk actors

Staphylococcus aureus
Coagulase-negative staphylococci
Streptococcus spp.
Neisseria gonorrhoeae
Enterobacteriaceae
Pseudomonas aeruginosa
Mycoplasma hominis
Candida spp.
Healthy adults, presence of risk factors (eg, diabetes
mellitus, skin breakdown, cutaneous infection),
previously damaged joint (eg, rheumatoid arthritis, IV
drug users, infective endocarditis)
After invasive articular manipulation (ie, synovial fluid
aspiration, joint infiltration, arthroscopy)
Healthy adults, splenic dysfunction, cutaneous
infection, infective endocarditis
Sexually active patients, promiscuity, complement
deficiency, associated tenosynovitis, and vesicular
pustules
Elderly patients, immunocompromised hosts,
urogenital or gastrointestinal infection
IVdrug users, immunocompromised hosts
Immunocompromised hosts, urogenital manipulations
IVdrug users, immunocompromised hosts

Ta b le 11.1-1 Microorganism s causing se ptic arthritis according to

patie nts risk factors.
Abbre viation: IV, intrave nous.

215
 Se ct io n 2Spe cial
situations
11.1Se ptic
arthritis
2 Sym p t o m s
Most patien ts (ie, 7885% ) presen t w ith an acu te on set o
join t sw ellin g an d pain . Th e pain is presen t at rest, aggra-
vated w ith w eigh t bearin g, an d th e join t m otion is lim ited.
Join t eryth em a an d excess h eat are presen t in m ost cases.
Fever is on ly ou n d in abou t 50% o patien ts, possibly
becau se an algesic an d an tiin f am m atory m edication s are
u sed [11]. Abou t h al o th e patien ts h ave a distan t in ection
ocu s an d m ay report dysu ria, u rin ary requ en cy, f an k pain ,
n au sea, vom itin g, diarrh ea, or a produ ctive cou gh .
3 Dia gn o s t ic p ro ce d u re s
3 .1 Clin ica l e xa m in a t io n
Th e a ected join t is pain u l on palpation an d m ovem en t.
Eryth em a, excess h eat, an d a palpable e u sion are presen t.
In h ip arth ritis th e latter sign s can be absen t an d pain du rin g
m ovem en t an d axial com pression is th e on ly clu e or in ec-
tion . Gen erally, a m on oarth ritis is presen t, in case o oligo-
arth ritis on e sh ou ld bear in m in d gon ococccal arth ritis,
especially i a coexistin g exan th em a is ou n d. Th e skin sh ou ld
alw ays be exam in ed or u n derlyin g skin diseases, eith er as
th e prim ary in ection ocu s (eg, abscesses, cellu litis) or as a
predisposin g actor or th e colon ization w ith S aureus (eg,
eczem a, psoriasis). Fu rth erm ore, th e patien t sh ou ld be
exam in ed or oth er prim ary in ection oci, in clu din g u ro-
gen ital, gastroin testin al, or pu lm on ary in ection s.
Th e di eren tial diagn osis o septic arth ritis m an i estin g as
acu te m on oarth ritis in clu des predom in an tly crystal-in du ced
arth ritis su ch as gou t (u rate crystals) an d pseu dogou t
(calciu m -pyroph osph ate crystals) ( Ta b le 11.1-2 ) [11, 23]. Th e
di eren tiation betw een septic an d crystal-in du ced arth ritis
is m ost ch allen gin g an d o ten im possible both clin ically an d
based on th e syn ovial w h ite blood cell (WBC) cou n t. Oth er
di eren tial diagn oses in clu de in f am m atory osteoarth ritis,
in f am m atory join t diseases (eg, rh eu m atoid arth ritis, pso-
riatic arth ritis, sarcoidosis, Stills disease) or reactive arth ritis
a ter gastroin testin al (eg, Campylobacter spp.) or u rogen ital
in ection s (eg, Chlamydia spp.) am on g oth ers [24, 25]. Fu r-
th erm ore, trau m a, h em arth rosis, ractu re, m en iscu s tears,
or osteon ecrosis (a ter trau m a or in steroid-treated patien ts)
sh ou ld be con sidered. Extraarticu lar diseases can also sim u late
septic arth ritis, su ch as ten osyn ovitis, skin in ection s (eg,
cellu litis or erysipelas), bu rsitis, or eryth em a n odosu m .
216
3 .2 La b o ra t o r y t e s t s
I septic arth ritis is su spected, blood in f am m atory param -
eters sh ou ld be exam in ed, in clu din g di eren tial WBC cou n t
an d C-reactive protein (CRP). Th e sen sitivity o a WBC cou n t
> 10,000 cells/ L is 90% an d a CRP > 100 m g/ L is 77% , bu t
both param eters are n on speci c [11]. As th e predom in an t
path om ech an ism in septic arth ritis is h em atogen ou s seedin g,
tw o pairs o blood cu ltu re sh ou ld be draw n or m icrobio-
logical an alysis; th ey are positive in abou t 50% o patien ts.
Fu rth erm ore, u rin e an d spu tu m cu ltu res sh ou ld be obtain ed
i u rogen ital or respiratory tract are su spected to be th e
prim ary in ection ocu s.
3 .3 Im a gin g
Im agin g is rarely n ecessary in th e acu te m an agem en t o
septic arth ritis. Con ven tion al x-ray detects preexistin g join t
diseases (ie, osteoarth ritis, rh eu m atoid arth ritis, osteom yelitis,
or ch on drocalcin osis). Ultrasou n d can be u se u l to gu ide
join t aspiration . Bon e scin tigraph y is u su ally positive a ter
10 days, is n ot speci c bu t m ay be h elp u l in th e diagn osis
o sacroiliac join t in ection . Com pu ted tom ograph y is sen sitive
or th e detection o bon e erosion s, join t e u sion an d so t-
tissu e in ection s. Magn etic reson an ce im agin g is even m ore
sen sitive; h ow ever, it is on ly requ ired or th e diagn osis o
stern oclavicu lar or sacroiliac arth ritis, sym ph ysitis, or post-
operative arth ritis ollow in g cru ciate ligam en t recon stru ction
[26, 27].
Di erential diagnosis Specif c diagnosis
Septic arthritis Bacterial, fungal, viral, mycobacterial arthritis
Crystal-induced arthritis Gout, pseudogout
Activated osteoarthritis Degenerative joint disease
Reactive arthritis Underlying urogenital (ie, Chlamydia spp. N gonorrhoeae)
or gastrointestinal infections (ie, Campylobacter spp.,
Salmonella spp., Shigella spp., Yersinia spp.)
Systemic rheumatic diseases Rheumatoid arthritis, psoriatic arthritis, sarcoidosis, systemic
lupus erythematosus
Trauma Hemarthrosis, fracture, osteonecrosis, meniscal tear
Tumor Osteosarcoma, chondrosarcoma, metastatic disease
Extraarticular disease Tenosynovitis, bursitis, cellulitis, erysipelas, erythema
nodosum, Bakers cyst
Ta b le 11.1-2 Diffe re ntial diagnosis of acute m onoarthritis.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Anna Conen, Olivier Borens

3 .4 Syn o via l flu id a n a lys is
Th e exam in ation o th e syn ovial f u id is th e m ost im portan t
diagn ostic tool in every patien t with su spected septic arth ritis.
Arth rocen tesis sh ou ld be per orm ed be ore an y an tim icro-
bial treatm en t is in itiated [11 , 2 8 ]. Th e syn ovial f u id sh ou ld
be an alyzed or th e ollow in g param eters (ordered by sig-
n i can ce):
1. Di eren tial WBC cou n t (u se EDTA tu bes to avoid
coagu lation )
2. Gram stain an d m icrobiological cu ltu re (in ocu late
pre eren tially pediatric blood cu ltu re bottles to
in crease cu ltu re sen sitivity)
3. Presen ce o crystals (u se n ative tu bes) ( Ta b le 11.1-3 )
In septic arth ritis, th e syn ovial lu id m acroscopically is
tu rbid or pu ru len t in 8090% o patien ts. Th e di eren tial
WBC cou n t h elps to n arrow th e di eren tial diagn osis: a
WBC cou n t o > 50,000 cells/ L h as a sen sitivity o 62%
an d a speci city o 92% or septic arth ritis; bu t m ain ly in
earlier stages o in ection an d in im m u n ocom prom ised pa-
tien ts lower WBC cou n ts can be expected, th ere ore a lim it
o > 20' 000 cells/ L sh ou ld be con sidered to be h igh ly
su spiciou s or septic arth ritis. I th e proportion o th e poly-
m orph on u clear leu kocytes is > 90% , th en sen sitivity is 73%
an d speci city 79% [11]. Oth er in f am m atory join t diseases,
eg, rh eu m atoid arth ritis or crystal-in du ced arth ritis, can
presen t w ith WBC cou n ts o 2,00050,000 cells/ L as w ell
an d especially crystal-in du ced arth ritis m im ics septic arth ri-
tis. Th e Gram stain is positive in on ly 50% bu t m icrobio-
logical cu ltu re in u p to 90% o patien ts w ith septic arth ritis
[11]. Th e m icrobiological diagn ostic yield can be in creased
i th e syn ovial f u id is in ocu lated in to pediatric blood cu ltu re
bottles [29 ]. I cu ltu re resu lts are n egative becau se patien ts
w ere pretreated w ith an tim icrobials or becau se o astidiou s
to grow or atypical m icroorgan ism s, bacterial DNA can be
iden ti ed by polym erase ch ain reaction [3 0 ]. Crystals, ie,
u rate an d calciu m -pyroph osph ate crystals, can be detected
by polarized ligh t m icroscopy o th e syn ovial f u id. Note th at
th e presen ce o crystals does n ot ru le ou t septic arth ritis, as
coexisten ce o crystals an d in ection h as been described
[3 1 , 32].

Clinical entity/ Parameter Normal Degenerative joint disease In ammatory joint disease Crystal-induced arthritis Septic arthritis
Clarity Transparent Transparent Translucent-turbid Turbid Turbid
Leukocyte count, cells/L < 200 2002,000 2,00020,000 > 20,000 > 20,000
Polymorphonuclear leukocytes, [%] < 25 2575 7090 > 90 > 90
Culture Negative Negative Negative Negative Positive

Ta b le 11.1-3 Diffe re ntial diagnosis of arthritis base d on synovial uid analysis.

217
 Se ct io n 2Spe cial
situations
11.1Se ptic
arthritis

4 Tre a t m e n t p rin cip le s
Th e key to su ccess u l m an agem en t o septic arth ritis is
early recogn ition o th e diagn osis, th e rapid in itiation o
appropriate an tim icrobial th erapy, an d join t drain age.
An tim icrobial treatm en t alon e is in su cien t to cu re septic
arth ritis [33]. I septic arth ritis is su spected, th e patien t sh ou ld
be m an aged as su ch u n til th e diagn osis is de n itively ex-
clu ded ( Fig 11.1-2 ). Th e m ain treatm en t goal is th e restoration
o a pain less u ll join t u n ction by th e eradication o in ection
w ith an tim icrobial agen ts an d by join t decom pression w ith
th e rem oval o in f am m atory e u sion [3, 9, 34, 35].
Be ore an y an tim icrobial treatm en t is started in a clin ically
stable patien t, m icrobiological an alysis o blood an d syn ovial
f u id is essen tial to iden ti y th e cau sative m icroorgan ism .
For th e m ech an ical an d su rgical treatm en t o septic arth ritis,
di eren t strategies can be ollow ed:
Repetitive n eedle aspiration s u n til th ere is a sign i can t
redu ction o in f am m ation (ie, decreasin g WBC cou n ts)
an d n egative m icrobiological cu ltu re resu lts
Arth roscopy
Arth rotom y( Ta b le 11.1-4 )
Th ere are on ly a ew stu dies com parin g di eren t su rgical
treatm en t strategies [3 6 , 4 2 ]. Th ere ore, th e selection o th e
drain age procedu re is depen den t on th e a ected join t (large
versu s sm all join ts), th e so t-tissu e con dition (presen ce o
abscesses or stu la), th e patien ts com orbidities, th e tim e
lag betw een th e on set o sym ptom s an d th e in itiation o
treatm en t (ch ron ic in f am m ation with com partm en talization ),
an d th e Gch ter stage ( Ta b le 11.1-5 ) [4346].
Th e u se o irrigation -su ction drain age system s in creases th e
risk o secon dary in ection s an d sh ou ld be avoided. Join t
irrigation w ith an tiseptics is con train dicated becau se m ost
an tiseptics (ch lorh exidin e an d polyh exan ide) lead to ch on -
drolysis an d destru ction o th e join t [47]. Th e adm in istration
o in traarticu lar an tim icrobial treatm en t is also con train di-
cated becau se a ch em ical syn ovitis can be in du ced [2 ].
Moreover, system ic an tim icrobial th erapy ach ieves excellen t
dru g levels in th e in ected join t, as th e in f am ed syn ovia is
w ell per u sed [48].

Joint pain and swelling

Differential diagnosis:
Inflammatory arthritis
No definitive alternative diagnosis Crystal-induced arthritis
Trauma, hemarthrosis
Bursitis, cellulitis

Synovial fluid aspiration:

Cell count
Presence of crystals
Gram stain and culture

Septic arthritis No septic arthritis

Surgical treatment: Antibiotic treatment:

Repetitive needle aspiration High dose and bactericidal initially
Arthroscopy IVtherapy
Arthrotomy Total treatment duration 46 weeks

Fig 11.1-2 Manage m e nt algorithm for se ptic arthritis.

Abbre viation: IV, intrave nous.

218 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Anna Conen, Olivier Borens

4 .1 Jo in t a s p ira t io n
Sm all periph eral join ts (eg, n ger an d toe join ts, w rist) can
be treated w ith repetitive n eedle aspiration s, i all n ecrotic
an d pu ru len t m aterial can be rem oved [38, 39]. Oth erw ise,
arth roscopic or open su rgical drain age m u st be per orm ed,
especially i com partm en talized f u id collection s are presen t.
In case o repetitive n eedle aspiration s, daily aspiration s are
n ecessary u n til treatm en t respon se is docu m en ted n ot on ly
clin ically bu t also m icrobiologically (ie, cu ltu re resu lts tu rn
n egative) an d by decreasin g WBC cou n ts in syn ovial f u id
an alysis.
Th e diagn ostic arth rocen tesis can already alleviate pain sym p-
tom s in m ost patien ts an d is th ere ore n ot on ly a diagn ostic
bu t also a irst th erapeu tic in terven tion . It rem oves th e
in f am ed syn ovial f u id w ith h arm u l en zym es an d toxin s
th at are dam agin g th e cartilage. How ever, on e aspiration is
rarely en ou gh an d is m ain ly in large an d w eigh t-bearin g
join ts (ie, kn ee, h ip, sh ou lder, elbow , an d an kle) on ly a
provision al treatm en t an d sh ou ld be ollow ed by rapid an d
aggressive su rgical join t lavage via arth roscopy to avoid
persistin g join t dam age.

Repetitive needle Arthroscopy Arthrotomy Stage Criteria

aspirations*
Small joints (eg, finger or
toe joints and wrist)
Patients with persistent or
recurrent (reactive) synovial
effusion after repetitive
arthroscopic lavages
Patients with high
perioperative mortality
Large, weight-bearing joints
(eg, knee, hip, shoulder,
elbow, and ankle)
Joints difficult to puncture
and drain by needle
aspiration (eg, hip and
shoulder)
Treatment failure of
repetitive needle aspirations
(eg, compartmentalized
joint effusion, adhesions)
Gchter stages 1, 2, and 3
Synovitis, cloudy fluid, possible petechiae, no radiological changes
1
Periarticular infection
2 Highly inflammatory synovitis, clumps of fibrin, pus, no radiological changes
(eg, abscess and fistula)
3 Thickening of the synovial membrane (possibly several centimeters), adhesions
with pouch formation, no radiological changes visible
Osteomyelitis, presence of
bone sequestra 4 Pannus formation, proliferation of aggressive synovitis on and later beneath the
cartilage (ie, subchondral erosions), radiological changes visible
Ta b le 11.1-5 Staging of se ptic arthritis as de ne d by Gchte r.
Need for emergency
decompression
Gchter stage 4
Prosthetic joint

Ta b le 11.1-4 Inte rve ntional and surgical tre atm e nt: whe n to use
re pe titive ne e dle aspirations, arthroscopy, and arthrotom y?
*
Daily re pe tition until white blood ce ll count in synovial uid
is de cre asing and culture re sults turn ne gative; ine ffe ctive in
com partm e ntalize d joint e ffusions; no joint irrigation possible .

Highe r intraope rative and postope rative m orbidity than arthroscopy

in nonprosthe tic joints.

Prior docum e ntation of m icrobiological re sponse (ne gative culture

re sults).

219
 Se ct io n 2Spe cial
situations
11.1Se ptic
arthritis
4 .2 Ar t h ro s co p y
In large w eigh t-bearin g join ts (eg, h ip, kn ee, sh ou lder, elbow ,
an d an kle) repetitive n eedle aspiration s are n ot en ou gh to
rapidly clean th e join t an d elim in ate in f am m atory e u sion .
Th ere ore, in th ese join ts, i a Gch ter stage 1, 2, or 3 is
presen t ( Ta b le 11.1-5 ) an d in patien ts w ith en capsu lated
in f am m atory f u id collection s, arth roscopic join t lavage as
soon as possible w ith h igh -volu m e f u id irrigation (abou t
9 L o eith er Rin gers solu tion or NaCl 0.9% solu tion ) is th e
th erapeu tic m eth od o ch oice [45, 46, 4951]. Com pared to
n eedle aspiration , arth roscopy allow s th e visu alization o
th e join t, th e rem oval o collection s an d adh esion s, leadin g
to a rapid decom pression an d m ech an ical clean in g o th e
join t. More severe in ection s, patien ts w ith a h istory o
in f am m atory arth ropath y an d in ection s cau sed by S aureus
o ten requ ire repeated arth roscopic in terven tion s [5 1 , 5 2].
Th e gen eral approach is to repeat arth roscopy every 23
days i n ecessary, depen den t on th e in itial in traoperative
presen tation an d th e clin ical respon se to su rgical an d an ti-
m icrobial treatm en t ( Fig 11.1-3 ). I a recu rren t syn ovial
e u sion a ter m u ltiple arth roscopies is presen t, in terim
n eedle aspiration s can be per orm ed i adequ ate respon se
to an tim icrobial th erapy h as been proven be ore (syn ovial
cu ltu res tu rn n egative). A n al arth roscopy m igh t be u se u l
to docu m en t th e en d o treatm en t resu lts. Th e ou tcom e is
depen den t on th e in itial stage o in ection . Cu re rates o
> 80% h ave been docu m en ted.
a b
Fig 11.1-3 a b Arthroscopic vie w of infe cte d joints.
a Gchte r stage 1.
b Gchte r stage 2 .
220
4 .3 Ar t h ro t o m y a n d p o s s ib le t re a t m e n t fa ilu re s
Open su rgical in terven tion , ie, arth rotom y, is n ecessary i
th e in ection is n ot con trolled by repetitive arth roscopy, in
Gch ter stage 4 disease ( Ta b le 11.1-5 ), i th ere is u n derlyin g
osteom yelitis or th e presen ce o bon e sequ estra or in patien ts
w ith a con tigu ou s spread o th e in ection in to th e su rrou n d-
in g so t tissu e w ith abscess orm ation [45 ]. Fu rth erm ore,
open su rgical debridem en t is m an datory in patien ts w ith
im plan ts or prosth etic join ts [53]. In earlier stu dies, arth ro-
tom y w as associated w ith a w orse u n ction al ou tcom e an d
a prolon ged h ospitalization w h en com pared w ith arth ro-
scopy [40, 41]. Com pared w ith repetitive n eedle aspiration s,
arth rotom y w as associated w ith a low er m ortality rate an d
a tren d or a sh orter h ospitalization [38, 39, 42]. How ever, in
all th ese older, retrospective an d sin gle-in stitu tion stu dies,
th e patien t n u m bers w ere sm all an d a selection an d treat-
m en t assign m en t bias can n ot be exclu ded. Th e selection o
th e treatm en t m odality, ie, n eedle aspiration versu s arth ro-
tom y or arth roscopy, m igh t depen d on th e m edical depart-
m en t in itially in volved, ie, su rgical or m edical, an d on th e
gen eral h ealth state o th e patien t: patien ts w ith m an y
com orbidities an d th ere ore a h igh er su rgical in terven tion
risk m igh t be exclu ded rom m ore in vasive procedu res an d
vice versa. Recen tly, two sm all stu dies com pared arth rotom y
an d arth roscopy in th e treatm en t o septic arth ritis an d
con rm ed th e earlier n din gs [36, 37]. Both stu dies ou n d
h igh cu re rates or both treatm en t m odalities (80100% ),
bu t a h igh er risk or a relapse o in ection an d a w orse
u n ction al ou tcom e in patien ts treated w ith arth rotom y.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Anna Conen, Olivier Borens
4 .4 Syn o ve ct o m y
For Gch ter stages 1 an d 2 ( Ta b le 11.1-5 ), syn ovectom y sh ou ld
n ot be carried ou t as th is redu ces th e di u sion o an tim i-
crobial agen ts in to th e join t, w h ich is acilitated by th e stron g
per u sion in th e in f am ed syn ovial m em bran e. For Gch ter
stage 3, arth roscopic sh avin g m ay also be con sidered, w h ile
an arth rotom y is pre erable i th e syn ovial m em bran e is
th ick. For Gch ter stage 4, an open syn ovectom y is recom -
m en ded [45 , 4 9 , 5 1 ].
4 .5 An t im icro b ia l t re a t m e n t
In addition to th e su rgical an d m ech an ical treatm en t, th e
adm in istration o h igh -dose an d bactericidal system ic an ti-
m icrobial th erapy is m an datory in th e m an agem en t o
septic arth ritis. Neith er treatm en t strategy alon e is su cien t
[33]. Th e isolation o th e cau sative m icroorgan ism is essen tial
or a targeted an tim icrobial th erapy w ith a lon g treatm en t
du ration . Th ere are n o ran dom ized con trolled stu dies eval-
u atin g th e e cacy o di eren t an tim icrobial treatm en ts.
Follow in g arth rocen tesis, em piric an tim icrobial th erapy is
adm in istered in traven ou sly an d gu ided by th e presen ce o
risk actors or septic arth ritis ( Ta b le 11.1-1 ) an d th e resu lts
o th e syn ovial Gram stain . In case n o m icroorgan ism s can
be detected in th e Gram stain , th e m ost com m on m icroor-
gan ism s cau sin g septic arth ritis sh ou ld be covered, ie, staph -
ylococci an d streptococci. In traven ou s am oxicillin / clavu lan ate
2.2 g every 8 h ou rs or in pen icillin -allergic patien ts IV
ce azolin 2 g every 8 h ou rs or IV ce u roxim e 1.5 g every 8
h ou rs are recom m en ded. In cou n tries w ith a h igh prevalen ce
o m eth icillin -resistan t S aureus em piric treatm en t sh ou ld
con tain IV van com ycin 15 m g/ kg body w eigh t every 12
h ou rs (van com ycin trou gh levels sh ou ld be h eld at 1520
m g/ L). I gram -positive cocci are detected in th e Gram stain
(su ggestive or staph ylococci or streptococci) th e sam e treat-
m en t regim en as or patien ts w ith a n egative Gram stain
resu lt is recom m en ded. I th e Gram stain sh ow s gram -n eg-
ative cocci (su ggestive or gon ococci or m en in gococci) IV
ce triaxon e 2 g per day is su ggested, an d i gram -n egative
bacilli are presen t IV ce triaxon e 2 g per day or IV ce epim e
2 g every 8 h ou rs i P aeruginosa is su spected. As soon as
syn ovial cu ltu re resu lts an d su sceptibility testin gs are available,
targeted treatm en t is in itiated [3, 54]. Th e targeted an tim i-
crobial treatm en t is su m m arized in Ta b le 11.1-6 .
Wh en ch an gin g IV to oral an tim icrobial th erapy, th e ollowin g
poin ts h ave to be respected. On ly an tim icrobial agen ts w ith
a good bioavailability an d bon e pen etration sh ou ld be u sed;
oth erw ise in su cien t dru g levels in th e bon e are ach ieved
w ith a con secu tive treatm en t ailu re. Th ere ore, th e au th ors
do n ot recom m en d u sin g oral am oxicillin / clavu lan ate or
oral ceph alosporin s or staph ylococcal septic arth ritis [55].
Fu rth erm ore, i an in ective en docarditis is presen t, th e u se
o an oral th erapy is con train dicated. In ective en docarditis
u su ally is treated w ith a h igh -dose IV th erapy or 46 w eeks
(2 weeks in streptococcal in ective en docarditis i com bin ation
th erapy is u sed). Th e au th ors also advise again st bacterio-
static treatm en t regim en s in septic arth ritis, in clu din g
clin dam ycin or staph ylococci or streptococci an d lin ezolid
or staph ylococci, streptococci, or en terococci. Be aw are th at
oral treatm en t com bin ation s w ith ri am pin sh ou ld n ot be
u sed in patien ts w ith staph ylococcal septic arth ritis i th ey
are sch edu led or a prosth etic join t im plan tation in th e n ear
u tu re (w ith in a year). Th e reason is th at ri am pin -resistan t
skin f ora em erges w h ich in case o a later postoperative
prosth etic join t in ection in creases th e probability o an
in ection with a di cu lt-to-treat m icroorgan ism (ie, ri am pin -
resistan t staph ylococci) [53].
Th e du ration o an tim icrobial th erapy is betw een 24 w eeks
or septic arth ritis cau sed by streptococci an d Haemophilus
spp. an d betw een 46 w eeks or septic arth ritis cau sed by
S aureus an d gram -n egative bacilli [3 , 5 6, 57]. In traven ou s
treatm en t du ration u su ally is 12 w eeks, depen den t on th e
cau sin g m icroorgan ism an d its su sceptibility pattern , th e
clin ical respon se to treatm en t, an d th e presen ce o a con -
com itan t osteom yelitis (Gch ter stage 4). An earlier sw itch
to th e oral th erapy is possible i th e m icroorgan ism s are
su sceptible to bactericidal oral treatm en t regim en s w ith a
good bioavailability an d bon e pen etration , su ch as ri-
am pin -con tain in g regim en s or staph ylococci an d f u oro-
qu in olon es or en terobacteriaceae.
221
 Se ct io n 2Spe cial
situations
11.1Se ptic
arthritis

Microorganism Antimicrobial agent Daily dose Application

Staphylococci: S aureus and coagulase-negative staphylococci
Methicillin-susceptible staphylococci Flucloxacillin* 4 x2g IV
Levofloxacin AND 2 x 500 mg Oral
Rifampin 2 x 450 mg Oral
OR
Trimethoprim/sulfamethoxazol AND 3 x 160/800 mg Oral
Rifampin 2 x 450 mg Oral
OR
Fusidic acid AND 3 x 500 mg Oral
Rifampin 2 x 450 mg Oral
OR
Doxycycline AND 2 x 100 mg Oral
Rifampin 2 x 450 mg Oral
Methicillin-resistant staphylococci Vancomycin# , OR 2 x 15 mg/kg body weight IV
Teicoplanin, OR 1 x 400 mg IV
Daptomycin 1 x 8 mg/kg body weight IV
Levofloxacin AND 2 x 500 mg Oral
Rifampin 2 x 450 mg Oral
OR
Trimethoprim/sulfamethoxazol AND 3 x 160/800 mg Oral
Rifampin 2 x 450 mg Oral
OR
Fusidic acid AND 3 x 500 mg Oral
Rifampin 2 x 450 mg Oral
OR
Doxycycline AND 2 x 100 mg Oral
Rifampin 2 x 450 mg Oral
Streptococcus spp. Penicillin G 4 x 5 Mio Units IV
Ceftriaxon 1 x2g IV
Amoxicillin 3 x 750 mg Oral
Enterococcus spp. Amoxicillin 4 x2g IV
With or without aminoglycoside||, OR IV
Daptomycin 1 x 10 mg/kg body weight IV
Amoxicillin 3 x 750 mg Oral
Enterobacteriaceae, gonococci, meningococci (quinolone susceptible) Ceftriaxon 1 x2g IV
Ciprofloxacin 2 x 750 mg Oral
Nonfermenters (eg, P aeruginosa) Cefepime, OR 3 x2g IV
Ceftazidime, OR 3 x2g IV
Piperacillin/tazobactam, OR 3 x 4.5 g IV
Meropenem 3 x2g IV
AND consider all with aminoglycoside**
Ciprofloxacin 2 x 750 mg Oral
Candida spp. Fluconazole 1 x 400 mg Oral
Caspofungin 1 x 70 mg IV
Anidulafungin 1 x 100 mg IV

Ta b le 11.1-6 Targe te d antim icrobial tre atm e nt in se ptic arthritis.

Note: The re sults of antim icrobial susce ptibility te sting are re quire d for targe te d tre atm e nt. Intrave nous tre atm e nt duration is 12 we e ks,
and total tre atm e nt duration is 2 6 we e ks, de pe nde nt on the m icroorganism , the clinical re sponse to tre atm e nt, and the pre se nce of a
concom itant oste om ye litis.
The indicate d dosage s are for adult patie nts with normal body m ass inde x, and norm al re nal and live r function. Abbre viation: IV, intrave nous.
*
In patie nts with a de laye d-type hype rse nsitivity to pe nicillin, IV ce fazolin 3 x 2 g or IV ce furoxim e 3 x 1.5 g pe r day can be use d.

In patie nts with an imm e diate -type hype rse nsitivity to pe nicillin, IV vancom ycin 2 x 15 mg/ kg body we ight pe r day (vancomycin trough
le ve l 15 20 mg/ L) or IV daptomycin 1 x 8 m g/ kg body we ight (and 1 x 10 mg/ kg body we ight in e nte rococcal infe ctions) pe r day should
be use d.

Rifam pin com binations should not be use d if a prosthe tic joint im plantation is planne d within the upcom ing ye ar. Oral tre atm e nt
com binations should not be use d if an unde rlying infe ctive e ndocarditis is pre se nt.

Afte r a single IV loading dose of 1 x 8 0 0 mg.
||
Intrave nous ge ntam icin 1 x 3 m g/ kg body we ight.

Two we e ks IV tre atm e nt re com m e nde d.
#
Vancom ycin trough le ve l 15 20 m g/ L.
**
Intrave nous ge ntam icin 1 x 3 (-5) m g/ kg body we ight or IV tobram ycin 1 x 3 (-5) mg/ kg body we ight.

Afte r a single oral loading dose of 1 x 8 0 0 m g.

Afte r a single IV loading dose of 1 x 20 0 mg.

222 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Anna Conen, Olivier Borens
4 .6 Ph ys io t h e ra p y
Ph ysioth erapy o th e in ected join t is im portan t an d n ecessary
to en su re th at th e cartilage is su pplied with n u trien ts th rou gh
di u sion [37, 54]. An in ected join t sh ou ld n ever be im m obilized
w ith extern al xation or in a splin t. Passive ran ge-o -m otion
an d isom etric exercises to bu ild u p stren gth accelerate reh a-
bilitation an d redu ce th e risk o su bsequ en t join t sti n ess,
u rth erm ore th ey preven t m u scu lar atroph y. For th e kn ee
an d h ip, a passive m otion brace is u se u l. In th e acu te ph ase
u n til drain s h ave been rem oved th e join t sh ou ld n ot bear
an y w eigh t, ie, bed rest or relie th rou gh tw o cru tch es is
recom m en ded, as is th e placem en t in a u n ction ally avorable
position to avoid con tractu res (n ot u lly exten ded).
4 .7 Pro gn o s is
Th e progn osis o septic arth ritis h as n ot im proved in recen t
years despite better an tim icrobial dru gs an d su rgical in ter-
ven tion strategies. Th e u n ction al progn osis is directly
related to th e presen ce o preexistin g join t disease, th e
viru len ce o th e cau sin g m icroorgan ism , an d th e th erapeu tic
delay betw een on set o sym ptom s an d start o adequ ate
th erapy [2, 45, 56, 58, 59]. Despite adequ ate th erapy, 2550%
o patien ts w ith septic arth ritis experien ce perm an en t join t
dam age w ith im paired join t u n ction . Th e m ortality rate is
depen den t on age, th e presen ce o com orbidities, an d im -
m u n osu ppression an d ran ges betw een 515% [56 , 5 8]. In
patien ts w ith a polyarticu lar in ection , m ortality rate is
h igh er an d m ay reach 30% [15].
5 Co n clu s io n
A h igh in dex o su spicion or septic arth ritis especially i risk
actors are presen t allow s a rapid in itiation o th erapy an d a
redu ction o com plication s. Early sign s o in ection sh ou ld
prom pt syn ovial lu id aspiration , w h ich is th e m ost im -
portan t diagn ostic w orku p ( Fig 11.1-2 ). Th e key to su ccess u l
m an agem en t o septic arth ritis is th e rapid in itiation o ap-
propriate an tim icrobial th erapy, an d join t drain age. An tim i-
crobial treatm en t alon e is in su cien t to cu re septic arth ritis.
Join t drain age can be ach ieved by arth roscopy, repetitive
n eedle aspiration s or arth rotom y depen den t on th e in volved
join t, th e exten t an d Gch ter stage o th e in ection . High -dose
an d bactericidal system ic an tim icrobial th erapy is adm in istered
in itially in traven ou sly. Th erea ter, oral treatm en ts w ith a
h igh bioavailability an d bon e pen etration are n ecessary.
Alth ou gh treatm en t is h igh ly e icien t, perm an en t join t
dam age is th e m ost im portan t com plication i adequ ate
th erapy is delayed.
223
 Se ct io n 2Spe cial
situations
11.1Se ptic
arthritis
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56. Ro s s JJ, Sa lt zm a n CL, Ca rlin g P, e t a l.
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1;36(3):319 327.
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Rh e u m a t o lo g y St a n d a rd s G, e t a l.
Gu idelin e or th e m an agem en t o th e
h ot swollen join t in adu lts w ith a
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Sep;58(3):492 493.
58. Ka a n d o rp CJ, Krijn e n P, Mo e n s HJ, e t a l.
Th e ou tcom e o bacterial arth ritis: a
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225
 Se ct io n 2Spe cial
situations
11.1Se ptic
arthritis

226 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Parag Sanche ti, AJ Ele ctricwala, Ashok Shyam, Kailash Patil
11.2 Se p tic a rth ritis a fte r a n te rio r cru cia te liga m e n t
su rge ry
Parag San ch e ti, AJ Ele ctricwala, Ash o k Sh yam , Kailash Patil
1 Ba s ics
In ection a ter an terior cru ciate ligam en t (ACL) recon stru ction
is an u n com m on bu t poten tially seriou s com plication , w h ich
can cau se sign i can t m orbidity, an d com plication s in clu din g
arth ro brosis an d articu lar cartilage loss [1]. In ection can
resu lt in perm an en t im pairm en t o kn ee u n ction th at does
n ot m eet th e h igh -dem an d per orm an ce expectation s o th e
patien ts u n dergoin g th is su rgery. Early diagn osis an d treat-
m en t are th e key actors in avoidin g th ese con sequ en ces
an d redu cin g th e len gth o h ospitalization [1].
Th ere are m an y algorith m s su ggested or treatm en t, bu t
th ere is n o con sen su s abou t th e best treatm en t m odality
[25]. Man y au th ors advocate eith er open or arth roscopic
debridem en t togeth er w ith in traven ou s an tibiotic th erapy,
bu t th ere is con siderable con troversy abou t gra t reten tion
[2 , 6 , 7 ]. Th ere is little eviden ce in th e literatu re on u n c-
tion al ou tcom es o th ese patien ts, especially w ith lon g-term
ollow -u p [1, 2, 7].
1.1 Ep id e m io lo g y
In ection a ter arth roscopic ACL recon stru ction (ACLR) is
a rare com plication w ith a reported in ciden ce o 0.30.48%
[2 4 , 8 1 2 ] an d a prevalen ce ran gin g rom 0.14 to 1.7%
[3, 4, 7, 10, 1316]. Th e in ciden ce o in ection a ter ACLR does
n ot vary by age, sex, or region [17].
Th e reported rates o in ection a ter ACLR h ave been con -
sisten t over th e past tw o decades in th e literatu re [17].
1.2 Ca u s a t ive m icro o rga n is m s
Staphylococcus species, speci cally th e su bspecies o
Staphylococcus aureus, in clu din g m eth icillin -resistan t
S aureus (31% ) an d coagu lase-n egative Staphylococcus
epidermidis (44% ), are th e bacteria respon sible or th e
m ajority o reported in ection s. Staphylococcus orm s
bio lm s th at protect it rom an tim icrobials, opson ization ,
an d ph agocytosis m akin g eradication di cu lt [18].
Propionibacterium saprophyticus is a rare cau sative
organ ism [18].
Win d an d colleagu es in 2001 reported on e case o
Candida albicans in ection ollow in g rou tin e arth ros-
copy o th e kn ee, w h ich even tu ally resu lted in a kn ee
u sion [19].
1.3 Re co gn it io n o f in fe ct io n a n d co n firm a t io n o f t h e
d ia gn o s is
Diagn osis o septic arth ritis is based on patien t h istory,
ph ysical exam in ation , laboratory param eters su ggestive o
an in ectiou s process, an d a cu ltu re o join t aspirate [15].
1.3 .1 Tim e to p re se n ta tio n
Th e average tim e to presen tation o in ection is 9.5 days
(m edian : 8 days) a ter recon stru ction . How ever, clin ical
eatu res m ay develop as early as 4 days an d as late as 20
days a ter su rgery [20].
227
 Se ct io n 2Spe cial
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11.2Se ptic
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cruciate
ligame nt
surge ry
1.3 .2 Clin ica l p a ra m e te rs
Typical param eters are [20 ]:
Fever w ith a tem peratu re ran gin g rom 37.6 C to
39.6 C, gen eral m alaise
Progressive in crease in kn ee pain an d sw ellin g
Large postoperative h em atom a
In creasin g in ection param eters in th e blood (C-reactive
protein (CRP), leu kocytes,
eryth rocyte sedim en tation rate (ESR))
Oth er less requ en t sym ptom s su ch as local in cision al
drain age, local w arm th , an d eryth em a
On ph ysical exam in ation , pain u l restriction in kn ee
ran ge o m ovem en t, sw ellin g, redn ess, an d disch arge
rom th e w ou n d m ay be ou n d ( Fig 11.2-1 )
Pu ru len t disch arge rom th e w ou n d, h yperem ic w ou n d
edges w ith local rise in tem peratu re m ay be presen t
( Fig 11.2-2 )
In d o le n t p re se n ta tio n o f se p tic a rth ritis a fte r a n te rio r
cru cia te liga m e n t re co n stru ctio n
In dolen t presen tation o th e disease w as em ph asized by
Sch ollin -Borg et al [20 ]. Th ey h igh ligh t th at w ell-kn ow n
sym ptom s o in ection m ay be m issin g, an d th e situ ation
can be easily in terpreted as n orm al postoperative n din gs
[20]. How ever, postoperative pain ou t o proportion to th e
su rgical pain , lon g-lastin g pain , an d th e absen ce o im prove-
m en t in sym ptom s sh ou ld raise th e level o su spicion or
septic arth ritis [15].
Fig 11.2 -1 Extraarticular graft site infe ction with ce llulitis.
228
Th e in cision or th e tibial tu n n el is th e m ost com m on site
or deep-w ou n d in ection becau se o its su per cial an a-
tom ical location [15].
1.3 .3 La b o ra to ry p a ra m e te rs
Th e param eters in clu de:
Both CRP an d ESR m ay be h elp u l in discrim in atin g a
n orm al join t rom a septic join t an d in evalu atin g th e
respon se o in ection to treatm en t. C-reactive protein is
a m ore sen sitive an d reliable in dicator o postoperative
in ection . Th e th resh old valu es o 41 m g/ L or CRP an d
32 m m / h or ESR h ave th e m ost optim al sen sitivity
(63% ) an d speci city (82% ) [21]. Th e peak CRP level
occu rs earlier th an th e peak ESR level a ter treatm en t
o postoperative in ection an d retu rn s to n orm al m ore
qu ickly [13]. Explan ation : CRP is a rapid-respon se
in dicator th at allow s prom pt treatm en t. Eryth rocyte
sedim en tation rate ref ects ch an ges in th e brin ogen
level, w h ich in creases a ter 2448 h ou rs o in ection ,
w h ereas th e CRP level in creases w ith in 68 h ou rs o
an in f am m atory process. C-reactive protein reach es its
peak valu e w ith in th e rst 3 days an d th en sh ow s a
aster retu rn to a n orm al valu e, w h ich u rth er proves
th at CRP is a m ore sen sitive an d reliable in dicator o
postoperative in ection [13].
Total leu kocyte cou n t > 10,000/ cu m m is su ggestive o
in ection [13].
Fig 11.2 -2 Purule nt discharge from arthroscopic portal
in a case of se ptic arthritis afte r arthroscopic ante rior
cruciate ligam e nt re construction.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Parag Sanche ti, AJ Ele ctricwala, Ashok Shyam, Kailash Patil

1.3 .4 Syn o via l flu id a sp ira tio n 3 Pre o p e ra t ive p la n n in g a n d s u rgica l a p p ro a ch

Join t aspiration sh ou ld be per orm ed as soon as th e diagn osis
o in ection is su spected. Th e join t f u id obtain ed m u st be
an alyzed (w h ite blood cell cou n t, di eren tial, crystals, an d
bioch em istry) an d cu ltu red or aerobic an d an aerobic organ -
ism s w ith an tibiotic sen sitivity [15]:
Elevated leu kocyte cou n t o aspirated kn ee-join t f u id
(average o 49.4 109/ L, n orm al: 411) w ith > 92%
polym orph on u clear cells is stron gly in dicative o septic
arth ritis [20].
Cu ltu re or aerobic an d an aerobic organ ism s an d
an tibiotic sen sitivity m u st be taken .
1.3 .5 Ra d io lo gica l p a ra m e te rs
Radiological evalu ation m u st in clu de an teroposterior,
lateral, an d Merch an t patellar view s [2]. X-rays m ay
reveal loosen in g o im plan t h ardw are ( Fig 11.2-3 ).
Magn etic reson an ce im agin g scan : su ggestive im agin g
sign s o in ection are appearan ces o syn ovitis, bon e
erosion s, periarticu lar edem a, an d f u id collection s or
abscesses [2224].
Early diagn osis an d treatm en t h ave been ou n d to be th e
m ost critical actors in th e h ealin g process an d avoidan ce o
com plication s.
3 .1 St e p s o f a r t h ro s co p ic la va ge
Th e list o steps to be taken in clu des [15]
1. Stan dard an terom edial an d an terolateral portals can
be u sed. A su perolateral portal m ay be added or
better in f ow
2. Exten sive w ash ou t o th e join t w ith 1015 L o
n orm al salin e solu tion
3. Debridem en t o in f am ed or devitalized tissu e
4. Rem oval o brin clots an d old coagu lated blood
5. Syn ovectom yi sign i can t syn ovitis is ou n d
6. Gen tle rem oval o th e brin layer th at covers th e gra t
su r ace
7. Macroscopic evalu ation o th e gra t or in tegrity
8. Syn ovial f u id an d debrided tissu e m u st be sen t or
n ew cu ltu re an d an tibiotic sen sitivity

2 In d ica t io n s fo r s u rgica l m a n a ge m e n t

Clin ical param eters su ggestive o in ection a ter ACLR:

Fever ran gin g rom 37.6 C to 39.6 C, eelin g o

gen eral m alaise
Progressively in creasin g kn ee pain an d sw ellin g
In creasin g in ection param eters
Large postoperative h em atom a
Oth er less requ en t sym ptom s su ch as local in cision al
drain age, local w arm th , an d eryth em a
On ph ysical exam in ation , pain u l restriction in kn ee
ran ge o m ovem en t, sw ellin g, redn ess, an d disch argin g
w ou n d
Pu ru len t disch arge rom th e w ou n d, h yperem ic w ou n d
edges w ith local in crease in tem peratu re
Fig 11.2 -3 X-ray showing loose ne d tibial
On ce th e diagn osis o septic arth ritis is con rm ed by th e xation scre w.
syn ovial aspirate as w ell as laboratory data, su rgical debride-
m en t m u st be carried ou t [15 ].

229
 Se ct io n 2Spe cial
situations
11.2Se ptic
arthritis
after
anterior
cruciate
ligame nt
surge ry

4 Ma n a ge m e n t a n d s u rgica l d e b rid e m e n t Sin ce th e pion eerin g w ork o Ballard, th e treatm en t or

Despite low in ciden ce o in ection a ter ACLR, it is im portan t
to recogn ize in ection an d treat it w ith ou t delay to preven t
th e devastatin g con sequ en ces su ch as articu lar cartilage
dam age an d arth ro brosis. How ever, optim al clin ical gu ide-
lin es h ave n ot been establish ed; th ere is n o con sen su s abou t
th e best treatm en t m odality. Bu rk an d colleagu es h ave
pu blish ed on th is su bject an d ou n d th at opin ion s di ered
or gra t preservation , type an d du ration o an tibiotics, an d
tim e o revision [16]. Man y au th ors recom m en d eith er an
open or arth roscopic debridem en t togeth er w ith in traven ou s
an tibiotic th erapy, bu t th ere is con siderable con troversy
regardin g gra t preservation [2 5 ]. Most au th ors agree th at
preservin g th e gra t an d repeatin g arth roscopic lavage as
m an y tim es as n ecessary w ou ld be th e best policy [2 , 6 ].
How ever, som e still believe th at gra t rem oval is an essen tial
part o th e h ealin g process [7].
septic arth ritis h as been based on a com bin ation o open
debridem en t an d join t irrigation [15, 31]. Riel an d colleagu es
reported on on e o th e rst series o patien ts w ith septic
arth ritis treated arth roscopically in stead o w ith open lavage
a ter ACLR th at h ad su ccess u l ou tcom es [32]. Sin ce th en ,
th is tech n iqu e h as been adopted worldwide by th e orth opedic
com m u n ity [15, 32]. On ce th e diagn osis o septic arth ritis is
con rm ed by th e syn ovial aspirate an d Gram stain as w ell
as laboratory data, an arth roscopic procedu re m u st be car-
ried ou t [1 5 ]. A ter th e in itial debridem en t, clin ical an d
laboratory param eters are rech ecked. I n ot im proved a ter
4872 h ou rs, arth roscopic irrigation an d debridem en t is
repeated. Arth roscopic debridem en t m ay be repeated u n til
th e clin ical an d laboratory param eters n orm alize. In th e
au th ors opin ion , several arth roscopic debridem en ts are
u su ally n ecessary.

4 .1 An t ib io t ic t h e ra p y
Th e aim o preoperative in traven ou s an tibiotics is to ach ieve
adequ ate plasm a an d tissu e levels o an tibiotics to redu ce
th e risk o bacterial exposu re. How ever, it is di cu lt or
im possible to ach ieve an tibiotic tissu e levels above th e m in -
im u m in h ibitory con cen tration in th e recon stru cted ACL
[18, 2530]. In patien ts w ith a su spicion o septic arth ritis, an
em piric in traven ou s trial w ith a com bin ation o broad-spec-
tru m an tibiotic su ch as ce tazidim e (2 g per 8 h ou rs) an d
van com ycin (1 g per 12 h ou rs) m u st be started [18, 2530].
Fig 11.2-4 An infe ction-
Th e an tibiotic th erapy m u st be later ch an ged accordin g to re late d brin laye r of the
th e sen sitivity o th e m icroorgan ism cu ltu red rom th e re constructe d ante rior
aspirate. Paren teral an tibiotics can be replaced w ith oral cruciate ligam e nt.
an tibiotics a ter 23 w eeks. An tibiotics m u st be adm in istered
or a m in im u m o 6 w eeks, an d th ey m u st n ot be w ith draw n
u n til com plete n orm alization o th e clin ical an d laboratory
param eters. Th e au th ors recom m en d paren teral an tibiotics
to be given u n til th e clin ical an d laboratory param eters im -
prove (CRP < 20, n egative-join t aspirate), or or a m in im u m
o 2 w eeks. Oral an tibiotics w ou ld be given th erea ter u n til
n orm alization o clin ical an d laboratory param eters (CRP
< 10), or or a m in im u m o 4 weeks. Th e au th ors recom m en d
a m in im u m total du ration o adm in istration o an tibiotics
o 6 w eeks.

4 .2 Su rgica l irriga t io n a n d d e b rid e m e n t Fig 11.2-5 A bacte ria-

induce d slim e laye r
Early diagn osis an d treatm en t h ave been ou n d to be th e
ove r the pre viously
m ost critical actors in th e h ealin g process an d avoidin g re constructe d ante rior
com plication s. Typical arth roscopic n din gs are dem on - cruciate ligam e nt with
strated in Fig 11.2-4 an d Fig 11.2-5 . e xte nsive synovitis.

230 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Parag Sanche ti, AJ Ele ctricwala, Ashok Shyam, Kailash Patil

5 Gra ft p re s e r va t io n ve rs u s gra ft re m o va l a n d In dication s or tw o-staged revision at th e au th ors

t w o -s t a ge d re vis io n
An algorith m ic approach is presen ted in Fig 11.2 -6 .
Cu ltu re-speci c in traven ou s an tibiotics an d ar-
th roscopic join t irrigation w ith gra t reten tion are
recom m en ded as in itial treatm en t.
Recom m en ded in dication s or gra t excision an d
h ardw are rem oval are in ection s cau sed by resistan t
organ ism s an d gra t in ection [7].
In su ch cases tw o-staged revision is recom m en ded:
Stage 1: radical debridem en t, gra t, an d h ardw are
rem oval.
Stage 2: revision ACLR a ter all clin ical an d laboratory
param eters h ave retu rn ed to n orm al.
in stitu tion are:
I th e recogn ition o in ection a ter ACLR h as been
delayed by m ore th an 2 w eeks a ter th e on set o
clin ical sym ptom s.
Wh en th e gra t looks in ected an d th e articu lar
cartilage appears to be at risk o dam age at th e tim e
o th e rst arth roscopic debridem en t.
Wh en th ere is n o progressive im provem en t in
clin ical an d laboratory param eters a ter ou r
con secu tive arth roscopic debridem en ts w h ere gra t
h as been preserved.
Persisten t positive-cu ltu re join t f u id a ter th ree
con secu tive arth roscopic debridem en ts.

High index o suspicion o in ection a ter ACLR

I. Clinical parameters
II. Laboratory parameters

Empiric IVantibiotics Synovial fluid aspiration Staining, culture, and antibiotic sensitivity

Culture-sensitive IVantibiotic for a Arthroscopic debridement I. Infected appearance of graft

minimum of 2 weeks OR until negative II. Loosening of hardware
joint aspirate III. Risk of articular cartilage loss

Culture-sensitive oral antibiotic for a I. Progressive improvement in clinical Absent

minimum of 4 weeks OR until complete and laboratory parameters
normalization of clinical and laboratory II. Negative joint aspirate
parameters

Gra t preservation Gra t and hardware removal

Two-staged revision

Fig 11.2 -6 Algorithm for the m anage m e nt of infe ction afte r arthroscopic ante rior cruciate ligam e nt
re construction. Abbre viations: ACLR, ante rior cruciate ligam e nt re construction; IV, intrave nous.

231
 Se ct io n 2Spe cial
situations
11.2Se ptic
arthritis
after
anterior
cruciate
ligame nt
surge ry
6 Po s t o p e ra t ive m a n a ge m e n t a n d re h a b ilit a t io n
On ce th e clin ical sym ptom s h ave n orm alized, a ph ysioth er-
apy program is in itiated. Th e reh abilitation protocol is n ot
sign i can tly di eren t rom cases w ith ou t in ection [15 ]. At
th e au th ors cen ter, th is reh abilitation program is ollow ed:
Con tin u ou s passive m otion o th e kn ee join t is begu n
at th e earliest possible tim e to preven t kn ee sti n ess.
On e w eek a ter su rgery, a graded kn ee-stren gth en in g
program , in clu din g qu adriceps an d h am strin gs
stren gth en in g th rou gh progressive isom etric, isoton ic,
an d isokin etic exercises, is started.
Ran ge o m otion is progressively in creased u n til at
least 120 o f exion is ach ieved.
Weigh t bearin g is allow ed at 4 w eeks u n til th e patien t
is am bu latory w ith cru tch es.
Fig 11.2 -7 Exte nsive synovitis 3
we e ks afte r ante rior cruciate ligam e nt
re construction.
Fig 11.2 -9 A crate r formation with
cat-bite appe arance of the m e dial fe m oral
condyle in a case of se ptic arthritis afte r
ante rior cruciate ligam e nt re construction.
232
7 Co m p lica t io n s
7.1 Ar t h ro fib ro s is
On e o th e m ost com m on com plication s o in ection s a ter
ACLR is arth ro brosis, w h ich in volves th e developm en t o
brou s scar tissu e w ith in an d arou n d th e syn oviu m in at
least on e com partm en t o th e join t ( Fig 11.2-7 , Fig 11.2 -8 ). Th is
m ay also develop di u sely [2 2]. Th is con dition is treated
w ith arth roscopic or open lysis o adh esion s.
7.2 Ar t icu la r ca r t ila ge d a m a ge
Articu lar cartilage dam age an d early on set osteoarth ritis is
a devastatin g com plication o in ection in a join t ( Fig 11.2 -9 ,
Fig 11.2-10 ). Hen ce, a h igh in dex o su spicion , early diagn osis,
an d treatm en t o in ection a ter ACLR are key to preven tin g
th is com plication .
Fig 11.2 -8 Infe ctious granulation tissue
and adhe sions in a case of stiff kne e
postinfe ction afte r ante rior cruciate
ligam e nt re construction.
Fig 11.2 -10 Articular cartilage loss in a case of
indole nt pre se ntation of se ptic arthritis se condary
to ante rior cruciate ligam e nt re construction.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Parag Sanche ti, AJ Ele ctricwala, Ashok Shyam, Kailash Patil
8 Pre ve n t io n m e t h o d s
Proper sterilization o su rgical equ ipm en t: in appropriate
sterilization tech n iqu e o th e h am strin g gra t h arvester
m ay be associated w ith th e in creased in ection rate.
Disassem blin g in stru m en ts w ith th is type o con gu ra-
tion (ie, tu be w ith in a tu be) is appropriate [33].
Preven tion o au togra t con tam in ation : a h igh rate
(12% ) o au togra t con tam in ation can be expected
du rin g au togra t preparation or ACLR [34, 35].
Rou tin e su rveillan ce or su rgical-site in ection s:
Periodic visible su rveillan ce m ay h elp keep su rgical-site
in ection rates dow n by en cou ragin g adh eren ce to
in ection con trol gu idelin es [17].
Avoid in traarticu lar corticosteroid in jection s [17].
Avoid preoperative razor sh avin g: i h air rem oval m u st
be per orm ed, it sh ou ld be don e im m ediately be ore
th e operation an d w ith electric clippers [17].
Avoid f ash sterilization : f ash sterilization is n ot
recom m en ded or rou tin e sterilization becau se it m eets
on ly m in im u m sterilization stan dards or tim e an d
tem peratu re. Th is is a particu lar con cern w ith
in stru m en ts su ch as arth roscopes, w h ich h ave a lon g
n arrow lu m en di cu lt to disin ect adequ ately w ith ou t
stan dard practices. Flash -sterilized in stru m en ts are also
easily con tam in ated du rin g tran sport back to th e
operative eld becau se th ey are n ot en closed in a
sterile con tain er [17 ].
9 Ou t co m e
Septic arth ritis a ter ACLR o ten does n ot resu lt in
in erior objective kn ee u n ction com pared w ith
u n com plicated ACLR [36].
Su bjectively, in ection patien ts are as satis ed as
n on in ection patien ts, bu t reh abilitation takes lon ger
an d ew er patien ts retu rn to play sports [36].
10 Co n clu s io n
Staphylococcus, speci cally th e su bspecies o S aureus,
in clu din g m eth icillin -resistan t S aureus (31% ) an d
coagu lase-n egative S epidermidis (44% ), are th e bacteria
respon sible or th e m ajority o reported in ection s.
In ection a ter ACLR m ay be in traarticu lar or extraar-
ticu lar. In traarticu lar in ection presen ts w ith eatu res
o septic arth ritis. Extraarticu lar in ection presen ts w ith
local w ou n d com plication s.
Th e average tim e to presen tation o in ection is 9.5 days.
In dolen t presen tation o septic arth ritis m ay be presen t
w h ere w ell-kn ow n sym ptom s o in ection m ay be
m issin g. Postoperative pain ou t o proportion to th e
su rgical pain an d th e absen ce o im provem en t in
sym ptom s sh ou ld be su ggestive or septic arth ritis.
C-reactive protein is a airly sen sitive an d reliable
in dicator o postoperative in ection .
Su rgical irrigation an d debridem en t com bin ed w ith
paren teral an tibiotics orm th e m ain stay o treatm en t.
A h igh in dex o su spicion , early diagn osis, an d treatm en t
o in ection a ter ACLR are th e keys to preven tin g
com plication s o septic arth ritis like arth ro brosis an d
articu lar cartilage dam age.
Early appropriate su rgery is essen tial.
Preven tion is better th an cu re. Proper sterilization o
su rgical equ ipm en t, preven tion o au togra t con tam i-
n ation , an d ideal operatin g room en viron m en t are key
to preven tion .
233
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situations
11.2Se ptic
arthritis
after
anterior
cruciate
ligame nt
surge ry
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20. Sch o llin -Bo rg M, Mich a ls s o n K,
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22. Ku lczycka P, La rb i A, Ma lgh e m J, e t a l.
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e t a l. M R im agin g o com plication s o
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e t a l. Meth icillin -resistan t
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van com ycin rom ten don s. Clin Orthop
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Fo rs s b la d M, e t a l. Postoperative septic
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Ste phe n L Kate s, Olivie r Bore ns
Paul W Millhouse, Cale b Behre nd, Ale xande r R Vaccaro
12 Sp o n d ylo d is citis
Pau l W Millh o u se , Cale b Be h re n d , Ale xan d e r R Vaccaro
1 Ba s ics
Historically, in ection s o th e vertebral colu m n w ere devas-
tatin g diseases. Spin al epidu ral abscesses w ere on ce rare bu t
alm ost u n iversally atal disorders [1, 2]. With th e adven t o
an tibiotics, advan ced im agin g, an d im provem en ts in su rgical
m eth ods, m orbidity an d m ortality h ave been dram atically
redu ced. Now , a tim ely diagn osis an d appropriate directed
an tim icrobial th erapy, an d w h en n ecessary, th e u se o
su rgery are th e essen tial elem en ts o su ccess u l m an agem en t
o th ese con dition s. Th is ch apter review s strategies u sed or
th e correct iden ti cation o patien ts at in creased risk or
in ection , typical presen tation s, prin ciples o diagn osis, an d
th e approach to treatm en t o spon dylodiscitis [3].
1.1 De fin it io n
Spon dylodiscitis is in ection or in f am m ation o th e disc
space, adjacen t en dplate, an d possibly th e vertebral body.
Th e in ection m ay in volve on e or m ore o th ese spin al
stru ctu res an d adjacen t spin al segm en ts as well as con tigu ou s
an atom ical region s. In its m ost severe orm , spon dylodiscitis
can lead to sepsis, spin al cord in ju ry (SCI) rom associated
abscess, spin al in stability, an d even death .
1.2 Pa t h o ge n e s is
Mech an ism s by w h ich m icroorgan ism s in ect th e vertebral
body or th e disc space in clu de h em atogen ou s or con tigu ou s
spread an d direct in ocu lation o th e disc space. Th e latter
can be trau m atic or iatrogen ic associated w ith diagn ostic or
th erapeu tic in terven tion s, su ch as spin al in jection , discograph y,
an d su rgery. Th e in ciden ce o iatrogen ic spon dylodiscitis is
in creasin g du e to th e in creased u se o in vasive treatm en ts.
Hem atogen ou s spread o in ection is m ore com m on w h en
associated with an oth er active in ection , tran sien t bacterem ia,
or in jection as w ith in traven ou s (IV) dru g u se. Th e m ost
requ en t sou rces o h em atogen ou s vertebral osteom yelitis
are u rin ary tract in ection s or th e tran sien t bacterem ia
associated w ith gen itou rin ary procedu res, ollow ed by
so t-tissu e an d respiratory in ection s [3 ]. On e com m on ly
accepted m ech an ism or h em atogen ou s spread in volves a
bacterial in ection o th e low f ow region s o th e vertebra
with su bsequ en t in volvem en t o th e en dplate with even tu al
destru ction o th e in tervertebral disc. Th e an atom y o th e
disc, en dplate, an d m etaph ysis vary w ith age, leadin g to
di eren t pattern s o in ection in ch ildren an d adu lts.
235
 Se ct io n 2Spe cial
situations
12Spondylodiscitis
1.3 Ep id e m io lo g y
Th e distribu tion o pyogen ic spin al in ection s is bim odal,
occu rrin g both in you n ger patien ts, o ten related to IV dru g
abu se, an d in th ose 5070 years old. Approxim ately h al o
th ose w ith osteom yelitis are older th an 50 years an d an even
greater predom in an ce o patien ts are m ale. Historically,
m ortality rom spin al in ection s w as h igh (u p to 71% ) [3].
With th e adven t o im proved diagn ostic im agin g, an tibiotic
th erapy, an d su rgical in terven tion , th e m orbidity an d m or-
tality h as decreased. How ever, w h en th e patien t is septic or
wh en an epidu ral abscess is presen t, relatively h igh m ortality
h as still been reported (1234% ) in som e series [47]. Wh en
an epidu ral abscess coexists th ere is also an associated h igh
rate o paralysis (2234% ) th at is irreversible in m ost cases
i m ore th an 24 h ou rs h ave passed rom th e tim e o on set
[68]. I iden ti ed early, th e treatm en t an d cou rse can be
m ore ben ign w ith m ost cases respon din g to an tibiotic
th erapy alon e. How ever, th e con dition is o ten m isdiagn osed
(u p to 50% o cases) or u n derm an aged w h ich con tribu tes
to th e m agn itu de o resu ltin g disability an d m ortality [9].
Th e in ciden ce o pyogen ic spin al in ection s in recen t stu dies
h as been h igh er th an in th e past. Th is is th ou gh t to be du e
to an agin g popu lation , greater prevalen ce o variou s co-
m orbid con dition s in clu din g alcoh olism , IV dru g u se, an d
im m u n osu ppression , as w ell as in creased u se o spin al
in terven tion s. Im proved diagn ostic ability m ay also play a
role w ith m ore requ en t u se o m agn etic reson an ce im agin g
(MRI) in th e last th ree decades [2, 7, 10 , 11 ].
Risk actors or establish ed in ection in clu de th e variou s
orm s o im m u n osu ppression , su ch as diabetes m ellitu s,
im m u n osu ppressive m edication s, an d gen etic or acqu ired
im m u n ode cien cy. In addition , pregn an cy, trau m a, IV dru g
u se, en d-stage ren al disease, alcoh ol abu se, m align an cy, an d
kn ow n septicem ia are all con tribu tin g con dition s. Lastly,
recen t spin al in jection s or su rgery are kn ow n risk actors
[2, 7, 10, 12].
236
2 Sym p t o m s a n d clin ica l s u s p icio n
Th e cou rse or in ection can be prolon ged by m isdiagn osis.
Most patien ts w ill h ave sym ptom s or several w eeks or m ore
be ore iden ti cation . Nearly all patien ts w ill presen t w ith
back pain (87% ), an d m an y w ill h ave ever (5270% ). Most
cases w ill n ot h ave an associated epidu ral abscess. Wh en
abscess or de orm ity is presen t, u p to 70% o patien ts w ill
h ave som e n eu rological n din g ran gin g rom radicu lopath y
w ith correspon din g pain an d w eakn ess, to m ore sign i can t
SCI [9].
Th e di eren tial diagn osis or back pain w ith ou t ever in clu des
m an y com m on con dition s th at overbu rden em ergen cy
departm en t sta an d spin e specialists alike. Th e list in clu des:
Osteodiscitis
Com pression ractu res
Degen erative disc disease
Facet arth ropath y
Spon dylosis or spon dylolisth esis
Osteoporosis
Psoriatic arth ritis an d oth er spon dyloarth ropath ies
Psych iatric disorders or addiction problem s w ith
m alin gerin g
In part, th is di cu lty con tribu tes to th e problem o m isdi-
agn osis. Patien ts w h o h ave a h istory o su bstan ce abu se or
psych iatric issu es w ith a ocu s on spin al com plain ts h ave a
h igh er association w ith IV dru g u se, alcoh olism , poorly m an -
aged diabetes, an d oth er risk actors or spin al epidu ral
abscess. Th ese patien ts are also m ore likely to h ave visited
th e em ergen cy departm en t in th e past, in creasin g th e like-
lih ood o m issin g th e diagn osis o an existin g discitis. Wh en
ever or n eu rological de cits are presen t, th e di eren tial
diagn ostic possibilities are dram atically ew er.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Paul W Millhouse, Cale b Behre nd, Ale xande r R Vaccaro
3 Sp in a l d ia gn o s t ic w o rku p
Spon dylodiscitis is o ten diagn osed in a delayed ash ion du e
to its n on speci c presen tin g sym ptom s. Th is poses a clin ical
ch allen ge becau se early diagn osis an d m edical treatm en t
w ith cu ltu re-directed an tibiotic th erapy can redu ce th e risk
or associated paravertebral abscess, epidu ral abscess, spin al
de orm ity, an d system ic in volvem en t. Early diagn osis also
decreases th e n eed or su rgical in terven tion .
Plain x-rays are o ten com m on early in an in ection . With in
24 w eeks x-rays m ay sh ow disc space n arrow in g, an d it is
typical at 46 w eeks to see osteolysis adjacen t to th e en d-
plate. Progressive kyph otic de orm ity can occu r an d patien ts
sh ou ld be ollow ed u p w ith periodic x-ray exam in ation s
du rin g treatm en t. Magn etic reson an ce im agin g w ith con trast
is th e stu dy o ch oice. Com pu ted tom ograph ic (CT) m yelogram
is 90% sen sitive i MRI is con train dicated.
In gen eral, or m ost severe in ection s w ith associated abscess,
laboratory m arkers are sen sitive bu t n ot speci c. Eryth rocyte
sedim en tation rate is elevated in 92100% o cases [1 3 ];
C-reactive protein is n early u n i orm ly elevated an d h as been
reported in som e stu dies to be progn ostic [14]. Wh ite blood
cell (WBC) cou n t is elevated in 4290% o cases, w h ile w ith
som e atypical or ch ron ic in ection s th e WBC cou n t can
o ten be n orm al. Blood cu ltu res are positive 2459% o th e
tim e an d are m ost h elp u l or ru lin g ou t in ection [12 , 13 ]. I
all laboratory m arkers are n egative in a patien t w ith n orm al
im m u n e u n ction , th e probability o in ection is sm all [3, 7,
13, 15].
4 Tre a t m e n t p rin cip le s
Th e stan dard o care is cu ltu re-directed IV an tim icrobial
th erapy. Alth ou gh m ost in ection s are cau sed by Staphylococ-
cus aureus, w ith oth er skin f ora an d gram -n egative rods
m akin g u p a lesser proportion , m ore th an 200 organ ism s
h ave been reported in th e literatu re in clu din g u n gal an d
parasitic species. Obtain in g an organ ism via su rgical biopsy
or CT-gu ided aspiration is a critical step in gu idin g an tibiotic
th erapy.
An oth er im portan t step in treatm en t is decidin g betw een
n on operative th erapy w ith IV an tibiotics alon e or w ith op-
erative in terven tion . In a retrospective review o 101 patien ts
w ith h em atogen ou s pyogen ic spin al in ection s, m ost w ere
spon dylodiscitis [1 5 ]. Hadjipivlou et al [1 5 ] developed an
algorith m to h elp gu ide su rgical decision m akin g ( Fig 12 -1 ).
4 .1 No n o p e ra t ive t re a t m e n t
In patien ts w ith spon dylodiscitis w ith ou t sepsis, n eu rolog-
ical de cit, abscess, de orm ity, or spin al in stability, th e best
available eviden ce in dicates n on operative treatm en t w ith
cu ltu re-directed an tibiotics. Th ere is recen t literatu re
eviden ce th at su pports n on operative treatm en t even in th e
presen ce o an epidu ral abscess w ith ou t sepsis or in stability,
w h ich h ave tradition ally been com pellin g in dication s or
su rgical in terven tion . Several sm all stu dies [1620] described
en cou ragin g resu lts or m edical treatm en t alon e in selected
patien ts w ith spin al epidu ral abscesses. In a larger series
Adogw a et al [21] con clu ded th at early su rgical decom pres-
sion with an tibiotics was n ot associated with su perior clin ical
ou tcom es com pared w ith IV an tim icrobials alon e or patien ts
50 years an d older.
Th ese n din gs w ere con troversial, h ow ever, an d tw o large
series [2, 22 ] reported a 3841% ailu re rate w ith m edical
m an agem en t alon e in th e settin g o spin al epidu ral abscess-
es. Delayed su rgery or ailed m edical m an agem en t w as also
associated w ith w orse n eu rological ou tcom es. Predictors o
poorer resu lts in clu ded in creased pain , degree o de cits,
dorsal abscess, diabetes m ellitu s, in creased C-reactive protein
or WBC on presen tation , positive blood cu ltu res, m eth icil-
lin -resistan t S aureus in ection , patien t older th an 65 years,
an d con com itan t SCI [2, 21, 22]. A review [15] o pyogen ic
spin al in ection s also con clu ded th at patien ts treated n on -
operatively m ore requ en tly reported residu al back pain
th an th ose w h o u n derw en t operative in terven tion .
Progn osticators or ailu re o m edical m an agem en t su ch as
th ese h elp gu ide treatm en t plan n in g. Non operative treatm en t
is typically avored [3] in th e settin g o com plete SCI lastin g
greater th an 24 to 36 h ou rs w ith ou t sepsis. Treatm en t
decision s are also gu ided by th e degree o de icits an d
patien ts; th ose w h o h ave pain alon e w ith su btle de cits an d
a stable Am erican Spin al In ju ry Association exam in ation
are gen erally m an aged n on operatively [9 ]. In addition ,
severity o pain can gu ide clin ician s tow ard operative in ter-
ven tion as th e am ily an d patien t m ay n ot tolerate m edical
m an agem en t alon e.
237
 Se ct io n 2Spe cial
situations
12Spondylodiscitis

4 .2 Op e ra t ive t re a t m e n t
Su rgical debridem en t, decom pression , an d recon stru ction
are th e treatm en ts o ch oice in th e settin g o de orm ity or
in stability. Oth er actors th at raise con sideration or su rgery
in clu de th e presen ce an d degree o n eu rological n din gs,
evolvin g de cits, sepsis, or th e persisten ce o in ection despite
an tibiotic th erapy. Variou s relative su rgical con train dication s
h ave been su ggested [2, 9 , 16 ], in clu din g m u ltilevel abscess,
i th e patien t is n eu rologically in tact, an d a com plete SCI
or m ore th an 24 h ou rs.
Stan dard su rgical treatm en t in clu des in cision , drain age, an d
debridem en t w ith cu ltu re-directed an tibiotics. For patien ts
w ith su bstan tial tissu e in volvem en t or w ell-establish ed
in ection , m u ltiple debridem en ts m ay be requ ired. Iden ti yin g
th ese cases or patien ts w ith a so t-tissu e de cit or di cu lt
w ou n d closu res is a ch allen ge. Delayed prim ary closu re,
reten tion o in stru m en tation , an d n egative-pressu re w ou n d
th erapy dressin g placem en t h as been reported w ith prom is-
in g resu lts in som e stu dies [3, 23]. On e sm all series also sh ow ed
good ou tcom es u sin g con tin u ou s irrigation [2 4 ]. Sin gle
debridem en t, prim ary w ou n d closu re, serial debridem en t,
f aps, an d n egative-pressu re dressin gs are oth er treatm en t
option s [3].

Early stage Advanced stage

+ No
Moderate bone destruction Extensive bone destruction
Concomitant psoas or paraspinal abscess
Moderate neurocompression with or Neural compression
without mild neurological dysfunction Neurological deficit

Yes Yes Yes

Minimally invasive surgery Anterior decompression

CT-guided percutaneous drainage
Percutaneous transpedicle discectomy Bone fusion
+
Yes Yes Posterior instrumentation
Exit No Deformity correction
Bone fusion
No
Yes
Deterioration or no improvement

No
Yes Yes
Failure Delayed complications of spondylodiscitis Painful pseudarthrosis Arthrodesis

Yes No
Yes
Open drainage Painful deformity Reconstructive surgery

No
Yes
Foraminal stenosis Foraminotomy

Fig 12 -1 Algorithm for surgical m anage m e nt of spondylodiscitis [15 ].

238 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Paul W Millhouse, Cale b Behre nd, Ale xande r R Vaccaro

5 In fe ct io n a ft e r s p in e s u rge r y in creased in ection risk. High er body m ass in dex h as been

Su rgical-site in ection s (SSIs) decrease h ealth -related qu ality
o li e, in crease risk o readm ission , prolon g th e len gth o
h ospital stay, an d raise h ospital ch arges w ith a cost esti-
m ated in recen t literatu re at USD 34,307 per in ciden t [25].
Th e in ciden ce varies by stu dy type, region o th e spin e, an d
in stitu tion ran gin g rom 0.7 to 19% . Th e h igh variability is
du e to di erin g su rgical sites, su rgical com plexity, an d patien t
actors. Large posterior th oracolu m bar su rgeries in th e
settin g o trau m a h ave th e h igh est rates o postoperative
in ection [26].
In addition to cost, in ection in creases risk to patien ts an d
is a sou rce o decreased satis action . In stu dies [27 , 2 8] con -
trollin g or pain an d oth er predictors o low er satis action ,
SSI w as sh ow n to decrease th e perception o su rgical su ccess.
In ection is also perceived by patien ts to be a con siderably
m ore severe even t th an by su rgeon s [27, 28].
Risk actors or in ection can be grou ped in to th ose th at are
patien t speci c, procedu re speci c, an d in traoperative ( Ta b le
12 -1 ). A CD4 cou n t low er th an 200 is a sign i can t risk actor
or in ection , w h ile patien ts w ith CD4 cou n t m ore th an 600
are n ot at in creased risk. For th ose w ith diabetes, a glu cose
level h igh er th an 125 m g/ dL is associated w ith a ve old
in creased risk o in ection . Maln u trition as in dicated by a
total lym ph ocyte cou n t o ew er th an 2,000 cells/ L or a
seru m albu m in level below 35 g/ L is also associated w ith
correlated w ith h igh er in ciden ce o com plication s w ith in
th e orth opedic literatu re in gen eral, h owever, recen t stu dies
by Meh ta et al [29 , 30 ] su ggest th at th e su bcu tan eou s at
th ickn ess m ay be a better predictor o risk or site SSIs.
As in m ost oth er areas o m edicin e, spin e su rgery patien ts
receivin g tran s u sion (s) are at in creased risk or postoperative
SSI. Tran s u sion -in du ced im m u n om odu lation is believed
to be th e u n derlyin g m ech an ism w ith e ects in m u ltiple
areas o n orm al im m u n e respon se. Tran s u sion s h ave also
been associated w ith in creased risk o sepsis an d death . A
system s-based approach to tran s u sion sh ou ld be adopted
by in stitu tion s to sa ely lim it u n n ecessary tran s u sion given
th e associated risks. A spin e su rgical in vasiven ess in dex th at
con siders th e type o spin e su rgery an d th e n u m ber o
vertebral levels an d presen ce o in stru m en tation h as re-
cen tly been in trodu ced. Th e com posite in dex valu e w as
de n ed as th e su m o in teger valu es assign ed to six procedu re
elem en ts, su ch as disc excision , gra t m aterial, an d in stru -
m en tation , based on th e n u m ber o vertebral levels in volved
[3 2 ]. Th e in dex w as in itially evalu ated in th e con text o
tran s u sion risk, an d w as later applied to in ection an d ou n d
to be correlated w ith in creased risk. Th is grou p in act sh ow ed
th at th e spin e su rgical in vasiven ess in dex w as th e stron gest
in depen den t risk actor or in ection a ter adju stin g or
oth er risk actors, su ch as age an d m edical com orbidities
[33, 34].

Factor OR (95% CI)

Cervical
Neurological disorder 2.61 (2.432.8)
Cardiac disorder (other than HTN) 2.17 (22.36)
Drug or EtOH abuse 1.85 (1.62.14)
Pulmonary disorder 1.38 (1.311.47)
Diabetes 1.28 (1.21.36)
Psychiatric disorder 1.22 (1.141.31)
HTN 1.09 (1.041.14)
Thoracolumbar
Neurological disorder 2.76 (2.553)
Drug or EtOH abuse 1.79 (1.641.95)
Cardiac disorder (other than HTN) 1.62 (1.531.71)
Pulmonary disorder 1.39 (1.311.48)
Cancer 1.31 (1.121.54)
Diabetes 1.12 (1.071.16)
Psychiatric disorder 1.1 (1.051.14)

Ta b le 12 -1 Signi cant patie nt risk factors for spine surgical-site

infe ction [31].

Abbre viations: CI, con de nce inte rval; EtOH, e thyl alcohol;
HTN, hype rte nsion; OR, odds ratio; SSI, surgical-site infe ction.

239
 Se ct io n 2Spe cial
situations
12Spondylodiscitis

In ection severity scores h ave also been u sed as predictors Th e u se o m in im ally in vasive tech n iqu es h as been stu died
o in ection in th e presen ce o m eth icillin -resistan t S aureus, exten sively to redu ce m odi able risk actors an d in ection
distan t in ection sites, presen ce o in stru m en tation , poste- rates. In a review article, Parker et al [38] ou n d m in im ally
rior su rgery, gra t m aterials, an d diabetes. A predictive in vasive tran s oram in al lu m bar in terbody u sion associated
m odel called th e postoperative in ection treatm en t score or w ith redu ced in ection risk com pared to tradition al tran s-
th e spin e (PITSS) w as bu ilt to h elp determ in e w h ich spin al oram in al lu m bar in terbody u sion procedu res. How ever,
SSI patien ts w ou ld requ ire m u ltiple irrigation an d debride- in discectom y procedu res, n o di eren ce w as ou n d u sin g a
m en t an d gu ide clin ical decision m akin g ( Ta b le 12 -2 ). Th is m in im ally in vasive approach com pared to open .
criterion w as developed rom a con secu tive series [3 5 ] o
128 patien ts based on 30 variables iden ti ed in a literatu re Sterile tech n iqu e rem ain s a u n dam en tal prin ciple or
review an d w as in tern ally validated again st th e sam e. in ection preven tion . Th e sterile eld gradu ally becom es
con tam in ated du rin g su rgery, w ith positive in traoperative
It is n ot su rprisin g th at trau m a patien ts are at in creased risk cu ltu res dem on strated in som e stu dies [39]. Th is is su pported
or in ection , w ith stu dies [36] reportin g a th ree old in crease by literatu re describin g h ow breaks in tech n iqu e an d m i-
in risk or patien ts u n dergoin g su rgery or SCI com pared crocon tam in ation also occu r in th e su rgical settin g [4 0 ].
w ith elective spin e su rgery. An elevated abbreviated in ju ry Oth er in vestigation s h ave exam in ed region s o C-arm steril-
scale grade speci cally h as been correlated w ith in creased ity, scru bs, gow n s, m icroscopes, an d even gra t m aterials
risk o in ection [37]. an d im plan ts dem on stratin g varyin g degrees o im pu rity,
in creasin g con tam in ation w ith prolon ged operative tim e,
an d varyin g in ectivity by region o operatin g room equ ip-
m en t sam pled. Oth er m eth ods o ten u sed to poten tially
preven t in ection s in clu de preoperative testin g or aggressive
path ogen s, an tibiotic proph ylaxis u sin g ce azolin w ith
Predictors PITSS score van com ycin or clin dam ycin , an d direct an tibiotic treatm en t
Spine location: o th e operative site u sin g agen ts su ch as van com ycin
Cervical 1
Thoracolumbar 2
pow der [41 , 4 2 ]. Th e u se o in traw ou n d van com ycin pow der
Lumbar/sacral 4 w ith povidon e-iodin e w ou n d irrigation w as sh ow n to sig-
Comorbidities: n i can tly redu ce rates o SSI by as m u ch as 50% .
None/other 0
Cardiovascular/pulmonary 1
Diabetes 4
Wh en postoperative in ection occu rs, early diagn osis an d
aggressive su rgical an d m edical m an agem en t can lead to
Microbiology:
Gram positive 2 su ccess u l resu lts. Th ere is sign i can t cost an d decreased
Gram negative or polymicrobial without MRSA 4 satis action on th e part o patien ts as w ell as practition ers.
Polymicrobial with MRSAor MRSAalone 6
Preven tion rem ain s th e best option w ith rigorou s sterile
Distant site infection:
tech n iqu e, appropriate an tibiotics, adju van t th erapy, m edical
None 1
UTI/PNA 3 optim ization o patien ts, an d care u l decision m akin g regard-
Bacteremia alone 5 in g th e in stitu tion o su rgical in terven tion .
Bacteremia +PNA/UTI 6
Instrumentation:
Yes 6
No 2
Bone graft:
None 1
Autograft 3
Other (allograft, BMP, and synthetic) 6

Ta b le 12 -2 Postope rative infe ction tre atm e nt score for the spine
to pre dict like lihood of re quiring two-stage re construction afte r
postope rative infe ction [31].

Abbre viations: PITSS, postope rative infe ction tre atm e nt score for the
spine; MRSA, m e thicillin-re sistant Sta phylococcus a ure us;
PNA, pne um onia; UTI, urinary tract infe ction; BMP, bone
m orphoge ne tic prote in; I&D, irrigation and de bride m e nt.

240 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Paul W Millhouse, Cale b Behre nd, Ale xande r R Vaccaro

6 Ou t co m e 7 Co n clu s io n

Th e requ en cy o relapse is low w ith 4 w eeks o m odern Early diagn osis an d appropriate treatm en t o spon dylodiscitis
an tibiotic th erapy an d close ollow-u p [13, 43]. Th e m ortality w ith cu ltu re-directed an tibiotics can avoid th e n eed or
rate is 516% depen din g on a patien ts age an d com or- u rth er su rgery. Failu re rates o m edical m an agem en t alon e
bidities, an d m ay be h igh er w ith S aureus th an w ith oth er are u p to 40% . Th e keys to su ccess are early iden ti cation
path ogen s [12]. In patien ts w ith epidu ral abscess, risk actors o th e organ ism s an d early in itiation o appropriate treatm en t.
or perm an en t n eu rological sequ elae in clu de advan ced age,
im paired im m u n ity, an d con com itan t diabetes m ellitu s or
rh eu m atoid arth ritis [3]. Th e ch an ce o spon tan eou s vertebral
u sion also in creases w ith in ection s h igh er in th e spin e,
rom 24% in th e lu m bar region to 75% in th e th oracic region
an d approach in g 100% in th e cervical spin e [44]. De orm ities
are m ore com m on w ith tu bercu losis bu t can also occu r w ith
pyogen ic in ection .

In term s o ou tcom e m easu res, patien ts w ith vertebral

osteom yelitis are poorly com pared to n orm al con trols.
Accordin g to a stu dy by ODaly et al [45], th e risk o adverse
ou tcom es is arou n d 66% , w ith resu ltin g sign i can t di er-
en ces in SF-36 an d Osw estry disability in dex scores an d
oth er h ealth m easu res. Delays in diagn osis an d n eu rological
de cit at presen tation w ere risk actors or adverse ou tcom e,
de n ed as persisten ce o pain , residu al disability, or death .

241
 Se ct io n 2Spe cial
situations
12Spondylodiscitis
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243
 Se ct io n 2Spe cial
situations
12Spondylodiscitis

244 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Sve n Hungere r, Mario Morge nstern

13 So ft-tis su e in fe ctio n s
Sve n Hu n ge re r, Mario Mo rge n ste rn

1 Ba s ics Th e US Food an d Dru g Adm in istration (FDA) h as categorized

SSTIs as u n com plicated an d com plicated. Un com plicated
Th e skin is th e largest organ an d covers th e w h ole body w ith SSTIs in clu de erysipelas, cellu litis, u ru n cles, an d sim ple
a su r ace area o approxim ately 2 squ are m eters. Besides abscesses; com plicated SSTIs in clu de in ected bu rn s an d
th e skin , so t tissu e in clu des m u scles, ten don s, ligam en ts, u lcers, deep-tissu e in ection s, an d m ajor abscesses. Th e n ec-
ascia, brou s tissu es, at, syn ovial m em bran es, n erves, an d rotizin g SSTIs are th eir ow n en tity [3]. Th e term s u n com pli-
blood vessels. cated or com plicated SSTIs establish ed by th e FDA are n ot
u se u l clin ically an d were developed to gu ide dru g com pan y
Skin an d so t-tissu e in ection s (SSTIs) are m u lti aceted an d stu dies [3].
ran ge rom m ild su per cial in ection s to deep n ecrotizin g
in ection s w ith seriou s system ic com plication s. Th ese in ec- Speci c description s based on path ogen esis an d clin ical
tion s can rapidly progress w ith a u lm in an t clin ical cou rse, m an i estation s are m ore relevan t or clin ical u se. Th ere ore,
requ irin g im m ediate recogn ition , an d treatm en t with proper di eren tiation in to categories o n on pu ru len t an d pu ru len t
m edical an d su rgical m an agem en t [1]. Th is ch apter provides in ection s h as su rgical con sequ en ces an d is m ore u se u l or
recom m en dation s or diagn osis an d treatm en t o su rgically clin ical care.
relevan t SSTIs in adu lt patien ts. Bacterial SSTIs in ch ildren
an d adolescen ts, eg, im petigo, are n ot covered in th is ch apter. An oth er clin ically relevan t classi cation w as described by
Kin gston et al [4] an d is based on u rgen cy o su rgical action
Th e treatm en t recom m en dation s are based on th e 2014 ( Ta b le 13 -1 ).
practice gu idelin es o th e In ectiou s Diseases Society o
Am erica or th e diagn osis an d m an agem en t o SSTIs as w ell
as on Eu ropean gu idelin es an d recen t literatu re an d recom -
m en dation s [2]. Progress and surgical action So t-tissue in ections
Slow progressive infections Furuncle
(generally nonsurgical Limited cellulitis
Th is ch apter provides a clin ical gu ide to prom ptly diagn ose treatment) Erysipelas
SSTI, iden ti y li e-th reaten in g n ecrotizin g disease pattern s, Impetigo
detect cau sative path ogen s, an d to u se in a tim ely ash ion Progressive infection of Abscess (including also: carbuncle, abscess after
th e appropriate an tim icrobial, adju van t, an d su rgical treat- moderate rapidity injection, perirectal abscess)
(urgent treatment) Septic bursitis
m en ts. Cellulitis
Paranychia
1.1 Cla s s ifica t io n o f SSTIs Rapidly progressive infections: Necrotizing fasciitis
Th ere are variou s m eth ods to classi y an d grade SSTIs aim in g severe life-threatening Fourniers gangrene
necrotizing soft-tissue Rabies
to direct th e appropriate treatm en t. Regardin g th e severity infections (NSTIs) Toxic shock syndrome
o th e clin ical cou rse, SSTIs can be di eren tiated in u n com - Gas gangrene with myonecrosis
plicated, com plicated, or n ecrotizin g SSTIs. Other NSTIs

Ta b le 13-1 Classi cation of soft-tissue infe ctions in te rm s of clinical

progre ss and urge ncy of surgical action (m odi e d from Kingston e t
al [4 ]).

245
 Se ct io n 2Spe cial
situations
13
Soft-tissue
infe ctions
Th e severity o th e clin ical cou rse is m ain ly correlated to
th e depth o th e SSTI. Th ere ore, depth o th e a ected skin
layer is an oth er essen tial criterion in de n ition an d classi-
cation o so t-tissu e in ection s ( Fig 13-1 ). Th e term s cel-
lu litis an d erysipelas are o ten u sed in con sisten tly becau se
th e clin ical di eren tiation m ay be di cu lt [5]. Th e distin ction
relates to th e depth o in f am m ation . Erysipelas is de n ed
as an in f am m ation o th e u pper layer o th e derm is in clu d-
in g th e su per cial lym ph atic system . Cellu litis a ects th e
deeper derm is as w ell as su bcu tan eou s at.
Clu es to severe deep so t-tissu e in ection are sym ptom s o
system ic illn ess (eg, ever, h ypoth erm ia, tach ycardia w ith
h eart rate > 100 beats/ m in u te, an d h ypoten sion w ith sys-
tolic blood pressu re < 90 m m Hg or 20 m m Hg below baselin e)
an d th e ollow in g clin ical sign s: pain disproportion ate to th e
ph ysical n din gs, violaceou s bu llae, cu tan eou s h em orrh age,
skin slou gh in g, skin an esth esia, rapid progression o in ec-
tion , an d gas in th e so t tissu e [5 ]. How ever, th ese sign s
occu r late in th e cou rse o a n ecrotizin g so t-tissu e in ection
(NSTI) an d are n ot alw ays presen t. In th ese cases im m ediate
su rgical evalu ation is th e prim ary ocu s or diagn ostic an d
th erapeu tic reason s.
In su m m ary, clin ical assessm en t o th e severity an d exten t
o th e in ection is cru cial. Th ere ore, several classi cation s
an d algorith m s or clin ical decision m akin g h ave been pu b-
lish ed [5, 6]. In clin ical rou tin e, th eir practicality is con tro-
versial an d th e ocu s sh ou ld be th e prom pt iden ti cation o
an y NSTIs, wh ich requ ire im m ediate su rgical an d an tibiotic
th erapy.
1 = Epide rm is 1 Etiological risk actors en com pass th e exten t o in ju ry. Th e
2 = De rm is
3 = Supe r cial fascia
4 = Subcutane ous 2
tissue
5 = De e p fascia
6 = Muscle
3
4 risk o developin g SSI are th e exten t o m icrobial con tam i-
5 n ation at an in cision site, du ration an d per orm an ce o th e
6 operation , th e len gth o preoperative h ospital period, an d
Fig 13-1 Skin and soft-tissue laye rs.
246
1.2 Ep id e m io lo g y
Skin an d so t-tissu e in ection s are com m on w ith a ren ew ed
im portan ce du e to dram atically in creased requ en cy an d
severity o th e in ection s [2 ]. In th e Un ited States, a 27%
in crease in h ospital adm ission s du e to SSTI w as recorded
rom 2000 to 2004. Em ergen cy departm en t visits in creased
rom 1.2 m illion in 1993 to 3.4 m illion in 2005. Most patien ts
w ith a m in or an d u n com plicated SSTI are seen an d treated
by th e ou tpatien t sector an d accou n t or 6.3 m illion ph ysi-
cian visits an n u ally. Th is in crease can be explain ed by th e
em ergen ce o an tibiotic-resistan t organ ism s, especially
com m u n ity-acqu ired m eth icillin -resistan t Staphylococcus
aureus (MRSA) in th e Un ited States.
1.3 Ris k fa ct o rs
Th e presen ce o risk actors or SSTIs in f u en ces th e strategy
an d su ccess o treatm en t an d m ay porten d th e clin ical cou rse.
Risk actors can be divided in to tw o categories: patien t-re-
lated an d etiological risk actors.
Patien t-related risk actors or developin g SSTI in clu de an y
con dition th at resu lts in an im m u n ocom prom ised state or
a ection o local blood su pply, drain age, an d im pairm en t
o th e skin barrier [7]. Mu ltiple patien t-related risk actors
correlate w ith a m ore rapid progression , w orse ou tcom es
an d h ealin g, an d are also associated w ith m ore resistan t
path ogen s [7].
System ic actors in clu de critical illn ess, old age, diabetes
m ellitu s, an im m u n e com prom ised state, obesity, in traven ou s
(IV)/ su bcu tan eou s dru g u se, alcoh ol abu se, m aln u trition ,
sm okin g, lon g-term corticosteroid th erapy, ch ron ic im m u n e
su ppression , can cer, kidn ey disease, an d liver disease. Local
actors in clu de periph eral vascu lar disease, ch ron ic u n gal
disease su ch as tin ea pedis, skin erosion s, or u lcers.
trau m a m ech an ism an d th e exposu re to th e en viron m en t
in crease th e likelih ood o a later w ou n d or su rgical-site in -
ection (SSI).
With SSIs, addition al su rgery an d in ju ry-related risk actors
h ave to be con sidered. Con tribu tin g actors in creasin g th e
preoperative procedu res like an tim icrobial proph ylaxis an d
skin preparation or h air rem oval [8, 9]. Im portan t system ic
patien t-related actors in creasin g th e risk o SSI are u n der-
lyin g com orbidities su ch as diabetes m ellitu s, rh eu m atoid
arth ritis, elevated seru m glu cose level, low h em oglobin
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Sve n Hungere r, Mario Morge nstern
level, as w ell as acu te u rin ary tract in ection s, im m u n o-
su ppressive m edication s, sm okin g, m aln u trition , or obesity
[10]. Staphylococcus aureus skin carrier statu s sh ou ld n ot be
n eglected, w h ich in creases SSI tw o old to n in e old [10] (see
ch apter 4 Preven tion o in traoperative in ection or m ore
SSI in orm ation ). Speci c risk actors or NSTIs are su m -
m arized in Ta b le 13 -2 .
Specif c risk actors
Renal insufficiency
Diabetes mellitus
Arterial occlusive disease
Intravenous drug abuse
Immunosuppression
Obesity (body mass index > 30 kg/m)
Age (> 65 years)
Liver disease
Trauma
Ta b le 13-2 Risk factors for ne crotizing soft-tissue infe ctions.
1.4 Micro b io lo g y a n d e t io lo g y
So t-tissu e in ection s are typically a bacterial in ection cau sed
by variou s path ogen s rom gram -positive to gram -n egative
species. On ce bacteria h ave breach ed th e skin barrier, th ey
can cau se SSTI, prom oted by above-m en tion ed predisposin g
actors. Speci c path ogen s are respon sible or particu lar
clin ical con dition s, w h ich are discu ssed in th e part o th is
ch apter on each speci c con dition [5].
1.5 Clin ica l m a n ife s t a t io n
Clin ical m an i estation di ers trem en dou sly depen din g on th e
exten t o th e u n derlyin g disease an d can ran ge rom localized
erysipelas or u ru n cu losis to u lm in an t NSTIs w ith system ic
sign s o in ection . Nearly all SSTI cases h ave th e classic sign s
an d sym ptom s o acu te in f am m ation : redn ess, pain , swellin g,
an d w arm th described by Celsu s (ca 30 BC40 AC) an d loss
o u n ction described by Galen (129200 AC) [12].
1.6 Dia gn o s is
Th ese ve clin ical m an i estation s or sym ptom s are h igh ly
valid or an on -th e-spot diagn osis o so t-tissu e in ection .
Th e prim ary aim o clin ical evalu ation an d in stru m en t-based
diagn ostics is to establish th e cau se an d severity o th e in ec-
tion , to recogn ize li e-th reaten in g in ection s, an d th ose
requ irin g im m ediate th erapy.
Th e patien ts h istory m u st be obtain ed care u lly becau se
so t-tissu e in ection s possess diverse etiologies. Th e h istory
m ay provide valu able clu es to th e likely iden tity o th e path o-
gen . In orm ation abou t th e patien ts im m u n e system , h is-
tory, m edication s (especially im m u n om odu latory th erapy),
an tim icrobial th erapy, dru g abu se, th e geograph ical location ,
travel h istory, recen t trau m a, recen t su rgery, an im al expo-
su re, bites, an d h obbies sh ou ld be obtain ed [2].
Th e ph ysical exam in ation sh ou ld docu m en t th e location an d
exten t o th e SSTI as w ell as presen ce o skin lesion s. Th e
above-m en tion ed classic sign s o in ection are sou gh t an d
skin redn ess can be m arked on th e skin to m on itor th e cou rse
o disease an d th e su ccess o th erapy. Speci c skin n din gs
o er clu es to certain etiologies an d su ggest speci c th erapy.
Palpable crepitu s is ou n d in gas- orm in g in ection s an d sh ou ld
raise su spicion o NSTIs an d in ection s cau sed by an aerobic
organ ism s, su ch as Clostridium per ringens. Skin n ecrosis can
be a h in t or NSTIs or advan ced arterial circu latory disorder.
Flu ctu an ce su ggests abscess orm ation , w h ich requ ires su r-
gical in terven tion . Bu llae an d pu rpu ra are seen in advan ced
stages o n ecrotizin g in ection s. Th e exam in ation sh ou ld
in clu de th e arterial pu lse statu s, ven ou s su cien cy, an d
lym ph atic statu s. Th e basic vital sign s, su ch as body tem -
peratu re, pu lse rate, blood pressu re, respiration s, an d m en tal
statu s, are essen tial elem en ts o every exam in ation .
Im agin g stu dies can be h elp u l or diagn osis. Ultrasou n d is
a ast, in expen sive, an d sa e diagn ostic tool to detect deep
in ection s, especially abscesses an d to estim ate th e location ,
size, an d exten t o th e abscess.
Radiograph ic exam in ation s m ay detect poten tial bon e in -
volvem en t, th e presen ce o an orth opedic device-related
in ection , an d to detect th e presen ce o gas or oreign bodies.
Magn etic reson an ce im agin g (MRI) or com pu ted tom ograph -
ic (CT) scan s m ay be h elp u l in su spected deep in ection s an d
is in dicated in su spected NSTIs to determ in e th e location an d
exten t o th e in ection . It can be com bin ed with an giograph y
to evalu ate th e arterial blood su pply. Th ese exam in ation s
provide u se u l in orm ation to plan su rgery bu t th ey sh ou ld
n ever delay a n ecessary su rgical in terven tion .
Laboratory exam in ation s are recom m en ded in every su s-
pected SSTI especially in pu ru len t, com plicated, an d severe
SSTI to iden ti y li e-th reaten in g disease pattern s an d to
m on itor treatm en t su ccess. Laboratory tests in clu de leu kocyte
cou n t, C-reactive protein (CRP) level, an d eryth rocyte sed-
im en tation rate. Th ese basic tests o er a pictu re o th e pa-
tien ts h ealth statu s. Rou tin e ch em istry tests an d coagu lation
stu dies iden ti y coagu lopath y or diabetes. In NSTIs, u rth er
stu dies su ch as seru m creatin e kin ase ( or m on itorin g m u scle
an d tissu e destru ction ) an d procalciton in or in terleu kin -6
m ay be h elp u l (see topic 2.7 o th is ch apter). In severe or
n ecrotizin g in ection s w ith system ic sym ptom s, aerobic an d
an aerobic blood cu ltu res sh ou ld be taken .
247
 Se ct io n 2Spe cial
situations
13
Soft-tissue
infe ctions

Th e an alysis o m icrobial grow th an d th e an tibiotic su scep-
tibility testin g provide im portan t in orm ation to re n e an d
direct th e de n itive an tibiotic treatm en t, w h ich is m an da-
tory in pu ru len t an d n ecrotizin g in ection s. In gen eral, th e
sam plin g is per orm ed in traoperatively accordin g to recom -
m en dation s listed in ch apter 7 Diagn ostics. Needle aspiration
can be u se u l in certain con dition s like bu rsitis bu t m ay be
con troversial. A su perin ection cau sed by recu rren t n eedle
aspiration sh ou ld be avoided.
1.7 Diffe re n t ia l d ia gn o s is
Th e di eren tial diagn osis o cellu litis an d erysipelas in clu des
allergen -triggered (con tact) derm atitis, cu tan eou s in f am -
m ation o gou t, h erpes zoster, an d th e lipoderm atosclerosis,
wh ich m ain ly occu rs in obese patien ts with lower extrem ity
ven ou s in su cien cy [5, 13].
1.8 Th e ra p y
Treatm en t o SSTIs an d ch oice o th e appropriate th erapy
requ ires evalu ation o th e local an d system ic statu s o th e
patien t to determ in e th e level o severity an d to categorize
in to n on pu ru len t or pu ru len t in ection s. Th e treatm en t op-
tion s in clu de basic prin ciples like rest, ice, an d elevation o
th e a ected extrem ity, a su rgical approach , an d/ or th e sys-
tem ic an tibiotic th erapy. Fig 13 -2 is a sim pli ed treatm en t
algorith m or SSTI th at con siders MRSA, adapted rom th e

Management o SSTIs
Nonpurulent Purulent
NSTI, cellulitis, erysipelas Furuncle, carbuncle, abscess,
septic bursitis

Severe: Moderate: Mild Severe Moderate Mild

Failed oral AB Systemic signs of Failed I&D + AB Systemic signs of infection
Septic patient infection Septic patient
Clinical signs of deeper Facial involvement
infection Impaired circulation
Immunocompromised
patients I&D + C&S I&D + C&S I&D

Intravenous AB Oral AB
(one each): (one each):
Penicillin Penicillin Empiric AB (one each): Empiric AB (one each):
Immediate Clindamycin Clindamycin Amino-PEN/BLI Amino-PEN/BLI
Acylamino-PEN/BLI Vancomycin Acylamino-PEN/BLI TMP/SMX
* *
Ceftriaxone (Ceph.3a) Cephalosporin 1/2
Cephalosporin 1/2 Daptomycin Cephalosporin 1/2 Doxycycline
* *
Cefazolin(Ceph.1) Isoxazolyl-PEN
Amino-PEN/BLI Isoxazolyl-PEN Linezolid* Isoxazolyl-PEN
Ceftaroline*
Surgical approach/evaluation
Rule out necrotizing infection
Radical debridement MSSA Calculated AB MRSA MSSA Calculated AB MRSA
Resection of necrotic tissue (one each): (one each):
Pus drainage Clindamycin Cephalosporin 1/2
Cephalosporin 1/2 see empiric Isoxazolyl-PEN see empiric
y
t
AB for US* AB for US*
i
l
Isoxazolyl-PEN
i
+
b
i
t
p
e
c
s
High dose empiric AB
u
s
d
(Fig 13-11 )
n
a
e
r
u
t
l
u
c
n
Intensive care medicine Fig 13-2 Tre atm e nt algorithm for soft-tissue infe ctions adapte d
e
g
o
from IDSA Guide line s 2014 with Europe an re com m e ndations.
h
t
a
P
*
The se are curre ntly re com m e nde d in the US but tre atm e nt options
Calculated AB will vary base d on the location of the re ade r (e g, re gions with high
(Fig 13-11 ) pre vale nce of MRSA).
Abbre viations: AB, antibiotic the rapy; I&D, incision and drainage;
Ce ph., ce phalosporin; C&S, culture and se nsitivity; MRSA, m e thicillin-
Second-look surgery
re sistant Sta phylococcus a ure us; MSSA, m e thicillin-susce ptible
(after 1236 h)
Sta phylococcus a ure us; TMP/ SMX, trim e thoprim -sulfam e thoxazole .

248 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Sve n Hungere r, Mario Morge nstern
2014 practice gu idelin es o th e In ectiou s Disease Society
o Am erica [2] an d in clu des recom m en dation s o th e Germ an
Pau l-Eh rlich Society o Ch em oth erapy. Th e Germ an gu ide-
lin es are developed or region s w ith a low rate o MRSA.
1.8 .1 An tim icro b ia l th e ra p y
Th e em ergen ce o an tibiotic resistan ce am on g th e com m on
path ogen s cau sin g so t-tissu e in ection s like MRSA an d
eryth rom ycin resistan ce in Streptococcus pyogenes is com -
m on ly observed. Th ere ore, it is recom m en ded th at em piric
an tibiotic th erapy in clu des agen ts w ith activity again st
resistan t strain s [5]. An tibiotic th erapy is divided in to an
em piric or targeted regim en . Em piric treatm en t is u sed w h en
th e iden tity an d su sceptibility o th e cau sative path ogen is
u n kn ow n .
Du e to th e an tibiotic resistan ce an d th e variety o m icroor-
gan ism s, an in terdisciplin ary approach sh ou ld be u sed w h en
treatin g bacterial in ection s. Th e su rgeon s ocu s sh ou ld be
im m ediate diagn osis, application o th e treatm en t algorith m ,
an d in itiation o th e appropriate em piric an tibiotic th erapy.
In term s o th e an tibiotic stew ardsh ip, an tim icrobial m edi-
cation sh ou ld be reassessed an d adapted to speci c path ogen s
an d su sceptibility pattern s in collaboration w ith an in ectiou s
diseases specialist.
Em p iric a n d ca lcu la te d a n tib io tic tre a tm e n t o f so ft-tissu e
in fe ctio n s
Min or SSTIs m ay be em pirically treated w ith sem isyn th etic
pen icillin , rst-gen eration or secon d-gen eration oral ceph -
alosporin s, m acrolides, or clin dam ycin [5]. I bacterial sam -
ples h ave been taken an d an alyzed, an tibiotic th erapy sh ou ld
be started as soon as possible, especially in patien ts w ith
n ecrotizin g in ection s, com plicated cases, an d n on respon ders
w ith assistan ce rom an in ectiou s diseases specialist.
Tre a tm e n t o f MRSA so ft-tissu e in fe ctio n s
In th e last tw o decades, MRSA h as em erged as a sign i can t
th reat w ith in th e h ospital en viron m en t, an d also to th e
h ealth y popu lation in th e com m u n ity settin g. It h as sh ow n
an in creasin g prevalen ce in STIs [14 , 1 5 ]. Recen t estim ates
su ggest MRSA cau ses m ore th an 11,000 death s, an d 80,000
in vasive in ection s in th e Un ited States per year [16 ]. Th e
cu rren t gu idelin es or an tibiotic treatm en t o MRSA SSTIs
are h igh ligh ted separately in th is ch apter. Doxycyclin e,
clin dam ycin , an d trim eth oprim -su l am eth oxazole h ave good
an tistaph ylococcal activities an d are recom m en ded as em piric
an tibiotic th erapy in region s w ith h igh rates o MRSA STIs
an d rst-lin e th erapy a ter path ogen iden ti cation [17]. Van -
com ycin , lin ezolid, an d daptom ycin h ave an excellen t
e cacy again st MRSA an d sh ou ld be reserved or patien ts
w ith severe in ection s or i previou s an tibiotic th erapy w as
n ot e ective ( Fig 13-2 ) [18 , 1 9 ].
1.8 .2 Su rgica l a n d n o n su rgica l tre a tm e n t
Su rgical an d n on su rgical treatm en t o SSTIs is n ot a con tra-
diction in term s. O ten th e n on su rgical treatm en t is n ecessary
to optim ize th e patien t an d h is or h er h ealth con dition to
m in im ize th e im pact o su rgery. Non su rgical treatm en t
sh ou ld n ot delay th e su rgical treatm en t i th e in dication is
vital. A rapidly progressive clin ical cou rse o SSTI requ ires
early su rgical in terven tion . Slow progress o in ection allow s
m ore tim e or diagn osis an d n on su rgical treatm en t.
No n su rgica l tre a tm e n t
Non su rgical treatm en t is o ten m u ltidisciplin ary to redu ce
risk actors (see topic 1.4 o th is ch apter) an d in clu des th e
treatm en t o th e u n derlyin g diseases, su ch as arterial occlu sive
disease, ven ou s in su cien cy, diabetes, n eoplastic an d para-
n eoplastic syn drom es. Elderly patien ts m ay experien ce
in tractable pru ritu s as adverse e ect o m edication s or m ay
develop deliriu m . Au toim m u n e an d con tagiou s in ection s
o th e skin , su ch as tin ea corporis, can dida, an d scabies,
n eed to be con sidered in th e di eren tial diagn osis.
Th e m u ltidisciplin ary care o SSTIs in clu des overall in tern al
m edicin e, derm atology, an d su rgery. Oth er disciplin es sh ou ld
be con su lted as requ ired.
In itial th erapy o so t-tissu e in f am m ation is m an aged ac-
cordin g to th e PRICE prin ciple, w h ich stan ds or protection ,
rest, ice, com pression , an d elevation , an d targets th e ve
classic sym ptom s o in lam m ation (see topic 1.5 o th is
ch apter). Protection an d rest can be easily ach ieved by bed
rest an d w ou n d dressin g. Dressin gs w ith an tiseptic solu tion
are an altern ative or ice an d avoid th erm al in ju ry. Most
patien ts keep th eir a ected extrem ities elevated by in tu ition .
Th e extrem ity can be su pported w ith pillow s. Com pression
an d lym ph drain age sh ou ld be don e w ith cau tion ; th is m igh t
be cou n terprodu ctive in acu te in lam m ation . Th e local
per u sion can be restricted by com pression .
Oth er treatm en t option s in clu de th e h yperbaric oxygen
(HBO) th erapy or critical w ou n ds. Th e eviden ce or HBO
is still con troversial [20]. In n ecrotizin g asciitis, HBO is som e-
tim es th e last h ope an d it sh ou ld n ot delay su rgical th erapy
[20]. Cen ters w ith HBO m ach in es o ten possess th e expertise
n eeded to treat th ese critically ill patien ts.
249
 Se ct io n 2Spe cial
situations
13
Soft-tissue
infe ctions
Su rgica l tre a tm e n t
Th e m ajor prin ciples o su rgical treatm en t w ere described
by Hippocrates (460370 BC): Ubi pu s, ibi evacu a, ie, w h ere depen din g on th e patien ts situ ation an d local con dition s.
you n d pu s, th ere you sh ou ld evacu ate it. Th is is th e su r-
gical objective to drain th e pu s, resect n ecrotic tissu e, an d
redu ce th e bacterial load. A h esitan t su rgical strategy resu lts
in a prolon ged clin ical cou rse an d w orsen s th e ou tcom e or
critically ill patien ts.
Negative-pressu re w ou n d th erapy (NPWT) h as em erged or
w ou n d care o SSTIs over th e last tw o decades [2 2 ]. Th e
ben e ts or NPWT w ere postu lated as redu ction o w ou n d
volu m e/ size, w ou n d-bed preparation an d aster w ou n d
h ealin g, decreased drain age tim e or acu te w ou n ds, en h an ce-
m en t o respon se to rst-lin e treatm en t, in creased patien t
su rvival, an d redu ction o cost ( Fig 13 -3 ) [2 3]. Th e NPWT
o ers som e poten tial advan tages su ch as patien t com ort. It
c c
250
is u su ally applied in th e operatin g room u n der sterile con -
dition s an d ch an ged a ter an in terval o u su ally 37 days
Plastic su rgery n eeds to be con sidered a ter m an agem en t o
th e in f am m atory process, i local w ou n d closu re can n ot be
ach ieved. Tech n iqu es vary rom m esh ed skin gra ts to local
or ree f aps. Th e assistan ce rom plastic su rgeon s is part o
th e m u ltidisciplin ary approach , w h ich is essen tial in th e
treatm en t o patien ts w ith in ection s.
An altern ative or additive option is biosu rgery. Biosu rgery
w ith sterile m aggots o th e com m on green bottle f y (Lu -
cilia sericata) is su itable or ch ron ic w ou n ds an d patien ts
w ith h igh in traoperative risk actors [24, 2 5]. Maggots are
n ot applicable in w ou n ds w ith in ten sive secretion or acu te
in f am m ation .
Fig 13-3 a c Ne crotizing soft-tissue infe ctions of the lowe r e xtremity.
a b Be fore and afte r surgical inte rve ntion: incision re ve als pus
drainage and ne crosis of de e pe r tissue laye rs, ie , fat and
m uscle ne crosis.
Wound cove rage with ne gative -pre ssure wound the rapy.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Sve n Hungere r, Mario Morge nstern
2 Sp e cific clin ica l m a n ife s t a t io n s
2 .1 Er ys ip e la s
2 .1.1 De fin itio n a n d clin ica l m a n ife sta tio n
Erysipelas, w h ich m ean s in an cien t Greek red skin , is
de n ed as an acu te in ection o th e u pper layers o skin an d
th e su per cial lym ph atic system . Th is disease appears as a
ery red, pain u lly ten der plaqu e w ith w ell-dem arcated
borders [5]. Th e clear lin e o dem arcation an d th e elevation
o th e in volved tissu e are path ogn om on ic eatu res o ery-
sipelas [2 6 ]. Th e m ost requ en t location is th e low er ex-
trem ity ( Fig 13-4 ) [27].
2 .1.2 Etio lo gy a n d m icro b io lo gy
Erysipelas is com m on ly cau sed by S pyogenes (serogrou p A)
an d oth er -h em olytic streptococci. Rare cau sative organ -
ism s are grou p B streptococci an d S aureus [27].
Th e portal o path ogen en try is a disru pted area o skin ,
w h ich is cau sed by local trau m a, u lceration , m acerated skin ,
ch ron ic u n gal in ection s (eg, tin ea pedis) or eczem a, an d
oth er in f am m atory skin disorders. Predisposin g actors are
a com prom ised local h ost de en ce an d con dition s prom otin g
skin ragility, su ch as obesity, previou s cu tan eou s trau m a,
an d edem a cau sed, or exam ple, by ven ou s or lym ph atic
in su cien cy [28].
2 .1.3 Dia gn o sis
Erysipelas is diagn osed by th e clin ical m an i estation o w ell-
dem arcated rash an d in f am m ation ( Fig 13-4 ). Blood cu ltu res
are n ot u se u l in com m on erysipelas or cellu litis an d are
on ly recom m en ded in cases o severe in ection w ith sys-
tem ic m an i estation [29]. Needle aspiration an d skin biopsies
are n ot in dicated rou tin ely an d m ay be m ore ben e cial in
patien ts w ith an im paired im m u n e system or a ter an im al
bites [30]. Th e borders o th e eryth em a can be m arked w ith
a w aterproo pen to m on itor th e cou rse o th e in ection an d
th e su ccess o th e in itiated an tibiotic th erapy ( Fig 13 -4 ).
Fig 13-4 Erysipe las of the lowe r le g: e ry re d e rythe m a
accom panie d by conside rable soft-tissue swe lling and we ll-
de m arcate d borde rs.
2 .1.4 Sp e cific tre a tm e n t
In con trast to pu ru len t in ection s w h ich requ ire su rgical
drain age, erysipelas an d cellu litis are best treated n on su rgi-
cally w ith an tibiotic th erapy [2]. Th is sh ou ld be accom pan ied
by su pportive th erapy, su ch as im m obilization an d elevation
o th e a ected area, to prom ote gravity drain age o th e
edem a [5].
Em piric an tibiotic th erapy or erysipelas an d cellu litis sh ou ld
cover streptococci like S aureus [5]. Depen din g on th e clin ical
severity it can be given paren terally or orally. In m an y cases
oral m edication s can be u sed, su ch as an tim icrobial agen ts
like pen icillin , am oxicillin , am oxicillin -clavu lan ate, diclox-
acillin , ceph alexin , or clin dam ycin ( Fig 13-2 ) [2, 5]. Du ration
o an tim icrobial th erapy sh ou ld be in dividu alized depen din g
on clin ical respon se bu t in gen eral 510 days is su cien t
[31]. In severely ill patien ts w ith system ic sign s o in ection ,
paren teral th erapy w ith pen icillin ase-resistan t pen icillin or
a rst-gen eration ceph alosporin sh ou ld be adm in istered [2,
5]. Severe cases h ave to be m on itored in th e h ospital settin g.
In patien ts w ith a pen icillin allergy, clin dam ycin or m oxi-
f ocaxin are altern ative ch oices; ceph alexin can be con sidered
i ceph alosporin s are tolerated [2, 5]. A ter im provem en t o
local an d system ic in ection , statu s paren teral th erapy can
be sw itch ed a ter 57 days to oral an tibiotics. Em piric cov-
erage or MRSA sh ou ld be con sidered in patien ts n ot re-
spon din g to in itial th erapy, patien ts w ith previou s episodes
o MRSA in ection or MRSA n asal colon ization , IV dru g
abu se, or patien ts w ith recu rren t skin in ection s w ith u n -
derlyin g risk actors. Th e MRSA treatm en t recom m en dation s
are IV dru gs, su ch as van com ycin , daptom ycin , lin ezolid
an d telavan cin , or oral th erapy with doxycyclin e, clin dam ycin ,
or trim eth oprim -su l am eth oxazole [2].
Com plicatin g actors th at m ay delay recovery are diabetes,
ch ron ic ven ou s in su cien cy, tin ea pedis, or lym ph edem a
an d sh ou ld be treated by appropriate th erapy.
251
 Se ct io n 2Spe cial
situations
13
Soft-tissue
infe ctions
2 .2 Ce llu lit is
2 .2 .1 De fin itio n
Cellu litis is an acu te exten sive spreadin g bacterial in ection
o th e derm is an d th e su bcu tan eou s at, w h ich can lead to
abscess orm ation .
2 .2 .2 Etio lo g y a n d m icro b io lo gy
Di u se cellu litis or in ection s w ith ou t a de n ed portal are
m ain ly related to streptococcal species, especially -h em olytic
streptococci. On th e oth er h an d S aureus is th e m ost com m on
bacteria in cases o cellu litis associated w ith u ru n cles, car-
bu n cles, or abscesses, an d th ose cau sed by pen etratin g
trau m a, in jection treatm en t, an d IV dru g abu se. Di eren t
path ogen s are respon sible or cellu litis related to trau m a,
w ater con tact, an d an im al, in sect, or h u m an bites [5]. Cel-
lu litis an d erysipelas presen t correspon din g etiology an d
path ogen esis.
2 .2 .3 Clin ica l m a n ife s ta tio n
Cellu litis occu rs as a rapidly spreadin g pain u l area o
edem a, h eat, an d redn ess w ith ou t sh arp borders. It can be
accom pan ied by lym ph an gitis an d in f am m ation o th e re-
gion al lym ph n odes or th rom boph lebitis [32]. On th e in f am ed
skin area, vesicles, bu llae, an d cu tan eou s h em orrh age
(petech iae) m ay be presen t ( Fig 13-5 ). Usu ally system ic sign s
o in ection s are m ild an d m ay be seen be ore skin m an i es-
tation s. In th e case o cu tan eou s h em orrh age in com bin ation
w ith severe sign s o system ic in ection sh igh ever, h ypo-
ten sion , tach ycardia, leu kocytosis, an d con u sion a deeper
NSTI sh ou ld be con sidered [5]. Recu rren t attacks o cellu litis
can lead to lym ph edem a.
Fig 13-5 Ce llulitis of the lowe r le g; pre se nting with no sharp
borde rs, ve sicle s, bullae , and cutane ous he m orrhage .
252
2 .2 .4 Dia gn o sis
Cellu litis is diagn osed by its clin ical m an i estation s w ith
u rth er con sideration s accordin g to th e disease pattern o
erysipelas.
2 .2 .5 Sp e cific tre a tm e n t
Cellu litis is treated in th e sam e m an n er as erysipelas.
2 .3 Fu ru n cle s a n d ca rb u n cle s
2 .3 .1 De fin itio n
Fu ru n cles are localized derm al or su bderm al in ection s o a
h air ollicle w ith a sm all abscess orm ation . Coalescen t-in -
ected ollicles w ith m u ltiple location s o pu s drain age are
de n ed as carbu n cle. Th ey occu r on h airy skin , particu larly
in th e axilla, in gu in al, th e u pper back, an d th e n eck [5].
2 .3 .2 Etio lo gy a n d m icro b io lo gy
Fu ru n cles an d carbu n cles are u su ally cau sed by S aureus.
Carbu n cles are o ten seen in patien ts w ith diabetes [5 ].
Staphylococcus aureus-related ou tbreaks o u ru n cu losis m ay
occu r in settin gs o close person al con tact associated w ith
skin lesion s an d in adequ ate person al h ygien e. In su ch
cases th e tran sm ission o path ogen s is acilitated by om ites
[3 3 35 ]. Repeated attacks o u ru n cu losis occu r in people
(especially in ch ildren ) w ith a com prom ised h ost im m u n e
respon se. In oth er cases, S aureus skin colon ization is th e
on ly iden ti able predisposin g risk actor in recu rren t u -
ru n cles, an d it rem ain s u n clear w h y som e carriers develop
a recu rren t skin in ection an d oth ers do n ot [36].
2 .3 .3 Clin ica l m a n ife s ta tio n
In itially, u ru n cles an d carbu n cles presen t as den se an d red
pain u l n odu les. With tim e, pu s orm ation w ith su bsequ en t
drain age or scar orm ation is seen .
2 .3 .4 Sp e cific tre a tm e n t
In cision an d drain age is requ ired in larger u ru n cles an d
carbu n cles, sin ce sm aller lesion s can be treated w ith m oist
h eat to prom ote drain age [5]. System ic an tibiotic th erapy is
solely recom m en ded in case o con ju n ction w ith exten sive-
su rrou n din g cellu litis or sign o system ic in ection [5]. In th e
case o recu rren t u ru n cu losis an d S aureus n asal colon ization ,
on e approach is decolon ization by m u pirocin application
[37].
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Sve n Hungere r, Mario Morge nstern
2 .4 Cu t a n e o u s a b s ce s s
2 .4 .1 De fin itio n
A cu tan eou s abscess is a collection o pu s w ith in th e derm is
an d th e deeper skin tissu es [38, 39].
2 .4 .2 Etio lo g y a n d m icro b io lo gy
Cu tan eou s abscesses are m ain ly polym icrobial an d con tain
skin an d adjacen t m u cou s m em bran e-colon izin g bacterial
f ora [3840]. Staphylococcus aureus is th e m ost com m on path o-
gen bu t on ly 25% h ave a sin gle disease-cau sin g path ogen
presen t [41].
2 .4 .3 Clin ica l m a n ife s ta tio n
Cu tan eou s abscesses presen t as pain u l, ten der, an d f u ctu an t
n odu les, w ith a cen tral pu stu le an d su rrou n din g eryth em -
atou s sw ellin g [38 , 3 9 ].
2 .4 .4 Dia gn o sis
Th e prim ary step in diagn osin g a cu tan eou s abscess is clin -
ical diagn osis an d obtain m en t o th e patien ts h istory w ith
ocu s on recu rren t abscesses or IV dru g abu se an d u rth er
risk actors. In m ost cases diagn osis is provided by clin ical
pictu re. Su per cial abscess can be seen or palpated. Ultra-
sou n d is a ast, in expen sive, an d easy diagn ostic tool to
con rm th e diagn osis, to detect deeper abscesses, an d to
determ in e th e size an d exten t o th e abscess. Laboratory
exam in ation is m an datory bu t en capsu lated abscesses o ten
lack elevated in ection param eters. An MRI or CT scan m ay
be h elp u l in su spected deep abscesses bu t are n ot in dicated
to diagn ose sim ple cu tan eou s abscesses. Bacterial cu ltu re
an d Gram stain o pu s rom abscesses are recom m en ded [2].
2 .4 .5 Sp e cific tre a tm e n t
Su rgical debridem en t w ith in cision , evacu ation o th e pu s,
an d exploration o th e cavity to detect locu lation s is th e
recom m en ded th erapy [2]. Th e su rgical site can be packed
w ith gau ze or covered w ith a dry dressin g. Larger abscesses
can be treated w ith NPWT, ollow ed by a secon d-look
su rgery. Su tu rin g th e w ou n d closed is an option bu t it
carries risk o recu rren t in ection an d sh ou ld be m on itored
closely [4 2, 43 ]. In traven ou s an tibiotics are recom m en ded
or system ic illn ess, su rrou n din g cellu litis, m u ltiple lesion s,
cu tan eou s gan gren e, an d in th e presen ce o com prom ised
h ost im m u n e de en ces, bu t is rarely n ecessary in u n com -
plicated cases [5]. An tim icrobial th erapy active again st MRSA
is in dicated in patien ts w ith abscesses or carbu n cles w h o
h ave an im paired h ost im m u n e system an d patien ts w ith
system ic in f am m atory respon se syn drom e [2]. Gu idelin es
or an tibiotic th erapy are listed in Fig 13 -2 , con siderin g in
addition recom m en dation s or th e US an d region s w ith h igh
prevalen ce o MRSA.
2 .5 Se p t ic b u rs it is
2 .5 .1 De fin itio n
A bu rsa is a so t-tissu e cu sh ion lin ed by a syn ovial m em bran e
to redu ce riction betw een so t-tissu e layersu su ally ou n d
adjacen t to a bon y prom in en ce. Th e m ost prom in en t bu rsae
a ected by bu rsitis are th e olecran on bu rsa an d prepatellar
bu rsa. Bu rsitis typically occu rs in m ale patien ts aged 4060
years an d can be divided in to th e com m on n on septic bu r-
sitis (NSB) an d septic bu rsitis (SB). Th e ocu s o th is ch apter
is on SB.
2 .5 .2 Etio lo gy a n d m icro b io lo gy
Non septic bu rsitis is m ain ly related to secon dary trau m a,
crystal deposition (ie, gou t or pseu dogou t), overu se by ath -
letes, or occu rs in certain occu pation al grou ps. It is du e to
a m ech an ical overload resu ltin g in an overprodu ction o
bu rsal f u id an d sw ellin g prom otin g th e cycle o ch ron ic
sterile in f am m ation .
In con trast, SB is an in f am m ation cau sed by in ection ,
typically resu ltin g rom bacterial in ocu lation . Staphylococcus
aureus represen ts th e m ost requ en t cau sative path ogen in
80% o cases, ollow ed by streptococci [44]. Gen erally, a skin
lesion is th e portal o path ogen en try bu t in rare cases h e-
m atogen ou s seedin g or spread rom an adjacen t cellu litis is
respon sible. Th e olecran on an d prepatellar bu rsae are in a
su per cial an d exposed location . Septic olecran on bu rsitis
occu rs ou r tim es as o ten as prepatellar bu rsitis. Oth er pre-
disposin g actors are rh eu m atoid arth ritis, alcoh ol abu se,
im m u n e de cien cy, an d h istory o ch ron ic bu rsitis.
2 .5 .3 Clin ica l m a n ife s ta tio n
Du e to sim ilar clin ical presen tation s, th e di eren tiation be-
tw een NSB an d SB is di cu lt. Th e m ost com m on sym ptom s
presen t in NSB as w ell as SB are bu rsal sw ellin g, redn ess,
an d ten dern ess. Bu rsal w arm th , ever, skin lesion s, or
in creasin g ten dern ess can be con sidered as decision criteria
or a septic in f am m ation . Som e patien ts w ith acu te SB m ay
presen t w ith a ever [45]. In su bacu te or ch ron ic cases, di -
eren tiation rom n on in ectiou s bu rsitis can be di cu lt.
2 .5 .4 Dia gn o sis
Diagn ostic m eth ods in clu de blood testin g, x-rays, u ltrasou n d,
an d bu rsal f u id aspiration to determ in e th e appropriate
treatm en t. Blood sam plin g sh ou ld in clu de th e typical in ec-
tion stu dies, sedim en tation rate, CRP level, an d w h ite blood
cell (WBC) cou n t. Biplan ar x-rays sh ou ld be obtain ed to
iden ti y u n derlyin g bon e lesion s, oreign bodies, or osteo-
m yelitis. Ultrasou n d can addition ally ch aracterize th e bu rsal
stru ctu re, en largem en t, an d con ten t. An MRI or CT scan
m ay be h elp u l in su spected deep bu rsal in ection (eg, o
253
 Se ct io n 2Spe cial
situations
13
Soft-tissue
infe ctions
th e pelvis) or in in ection s in volvin g th e adjacen t so t tissu e
[46].
Bu rsal aspiration is typically recom m en ded to con rm clin ical
n din gs. Macroscopic ch aracteristics o th e aspirate can su g-
gest th e in ectiou s etiology [46]. Pu ru len t aspirates in dicate
a septic etiology in con trast to th e clear, h em orrh agic or
m ilky f u id su ggestin g a sterile n on septic in f am m ation . Th e
laboratory an alysis o th e aspirate in clu des Gram stain , bac-
terial cu ltu re, WBC cou n t, an d bu rsal f u id glu cose level
[47]. Th e m ost speci c test in dicatin g a bacterial in ection is
a positive Gram stain or bacterial cu ltu re, w h ich also allow s
targeted an tibiotic th erapy. A WBC cou n t o m ore th an 3,000
cells/ L an d a total bu rsal f u id glu cose low er th an 31 m g/
dL or f u id-to-seru m ratio less th an 50% are con sidered
u rth er criteria su ggestin g SB [48].
Th u s, n eedle aspiration is critical bu t it bears th e risk o a
su perin ection i n ot per orm ed properly. Wh en recu rren t
n eedle aspiration is u sed or treatm en t, a ch ron ic in ection
situ ation m ay becom e establish ed. From a legal poin t o
view it is h ard to prove th at th e bacterial in ection o a
bu rsa is n ot cau sed by th e aspiration .
2 .5 .5 Sp e cific tre a tm e n t
In in ected an d n on in ected bu rsitis, n on steroidal an tiin -
f am m atory dru gs, an d th e PRICE m eth ods, con sistin g o
protection , rest/ im m obilization , ice, com pression , an d
elevation are recom m en ded an d sh ou ld be u sed or 1014
days [48]. Bu rsal aspiration is also su ggested in both cases to
relieve pain , in crease ran ge o m otion , an d to diagn ose th e
etiological path ogen s [48]. Aspiration in SB resu lts in both
drain age an d a redu ction o th e bacterial load. Th e in itial
classi cation o bu rsitis rem ain s im portan t to n on operative
or su rgical treatm en t. In SB, th e appropriate an tibiotic
treatm en t is th e keyston e an d sh ou ld be started w h en an
in ection is su spected. Sin ce S aureus is cau sative in approx-
im ately 80% o cases, th e em piric an tibiotics sh ou ld h ave
an tistaph ylococcal activity [48]. In region s w ith h igh preva-
len ce o MRSA in ection s, clin dam ycin , doxycyclin e, or oral
trim eth oprim su l am eth oxazole is recom m en ded [48].
In m ild an d m oderate cases o SB, am bu latory, oral an tibi-
otic th erapy or 2 w eeks is recom m en ded an d u su ally su -
cien t, as th e an tibiotics h ave been sh ow n to ach ieve h igh
in trabu rsal levels [48]. In severe cases w ith progression o
local n din gs or accom pan yin g system ic sign s o in ection ,
h ospitalization an d IV an tibiotic treatm en t or 10 days is
u su ally requ ired. In gen eral, th e du ration o an tibiotic
th erapy sh ou ld be determ in ed by th e clin ical cou rse, respon se
to th e th erapy, cu ltu re resu lts, th e im m u n e statu s, an d h ealth
o th e h ost [4 8 ]. Most patien ts respon d to n on su rgical
254
th erapy. How ever, in cases o a recu rren t SB a ter ailed
n on operative th erapy bu rsectom y is in dicated. Su rgical bu r-
sectom y sh ou ld n ot be per orm ed in an acu tely in f am ed
bu rsa. In th e literatu re, recu rren t n eedle drain age is described
bu t th e au th ors ear th e risk o su perin ection an d recom m en d
com plete bu rsectom y w h en n eeded.
Su rgical th erapy w ith bu rsectom y is in dicated in cases o
severe system ic in ection w ith in volvem en t o th e su rrou n d-
in g tissu e or com plication s, su ch as cellu litis, abscess orm a-
tion , or skin n ecrosis [48]. In th ese cases, in terven tion sh ou ld
be per orm ed u rgen tly to redu ce th e bacterial load an d to
preven t u rth er spread o in ection . In traven ou s an tibiotics
are recom m en ded or 7 days [4 8 ] an d can be prolon ged
accordin g to th e clin ical cou rse in severe cases. In olecran on
bu rsitis, th e skin in cision sh ou ld n ot be placed over th e bon y
olecran on process to avoid w ou n d-h ealin g di cu lty an d a
sen sitive scar [4 9 ]. In severe in f am m ation w ith sw ellin g,
in du ration , an d obscu red so t-tissu e layers, th e cou rse o
th e u ln ar n erve sh ou ld be con sidered. In prepatellar bu rsitis
a h orizon tal in cision alon g th e skin olds is th e stan dard.
Prim ary w ou n d closu re sh ou ld be ach ieved an d sh ou ld be
per orm ed w ith ou t skin ten sion . In cases w ith skin de ects,
eg, a ter excision o n ecrotic tissu e, m assive sw ellin g, or
su spected n ecrotizin g in ection , an NPWT closu re or con -
tin u ou s drain age can be u sed. An early secon dary w ou n d
closu re sh ou ld be th e goal an d recu rren t debridem en t w ith
ch an ge o th e n egative-pressu re w ou n d sealin g is an excep-
tion . A ter open bu rsectom y, th e extrem ity sh ou ld be im -
m obilized u n til proper w ou n d h ealin g h as occu rred. Th e
u pper extrem ity is splin ted in f exion , w h ereas or th e
low er extrem ity a brace is su cien t. Com plication s in clu de
w ou n d-h ealin g problem s, developm en t o a su bcu tan eou s
h em atom a, ch ron ic pain , an d in rare cases, recu rren t in ec-
tion s [49]. Th e arth roscopic bu rsectom y is described in th e
literatu re as an altern ative m eth od w ith decreased com pli-
cation s in term s o w ou n d-h ealin g disorders. Th e au th ors
recom m en d open bu rsectom y, especially in cases o acu te
in f am m ation to provide com plete rem oval o in ected tissu e
an d to avoid path ogen spread in th e adjacen t tissu e.
Th e key m essage: in SB, an tibiotic th erapy is th e key elem en t,
an d sh ou ld be in itiated i an in ection is su spected an d
accom pan ied by th e PRICE sch em e. Open bu rsectom y is
recom m en ded i severe system ic in ection resu lts rom
bu rsitis w ith in volvem en t o th e su rrou n din g tissu e or com -
plication s, su ch as cellu litis, abscess orm ation , or skin n e-
crosis as w ell as in re ractory cases. Recu rren t in ection an d
ailed n on operative th erapy requ ire su rgical in terven tion ,
w h ich sh ou ld n ot be per orm ed in th e settin g o acu te
in lam m ation . En doscopic bu rsectom y is an altern ative
su rgical m eth od th at th e au th ors do n ot recom m en d.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Sve n Hungere r, Mario Morge nstern
2 .5 .6 Pro gn o sis
Especially in cases o in adequ ate treatm en t o th e in ection ,
eith er by in su cien t an tim icrobial th erapy or su rgical de-
bridem en t, persisten ce o path ogen s can resu lt in recu rren t
in ection s. Most cases o SB resolve w ith n eedle aspiration
an d appropriate an tibiotic th erapy.
2 .6 So ft-t is s u e in fe ct io n s a s co m p lica t io n a ft e r
t ra u m a a n d s u rge r y
2 .6 .1 Su rgica l-site in fe ctio n
Su rgical-site in ection is th e m ost com m on adverse even t
in su rgical patien ts an d th e th ird m ost com m on n osoco-
m ial in ection w ith an average in ciden ce o 2.6% [5052].
Th e requ en cy, h ow ever, is depen den t on th e in ju ry pattern
an d localization , so t-tissu e dam age, an d patien ts com or-
bidities, w h ich allow a categorization rom clean an d low -risk
operation s to h igh -risk procedu res [53]. In th is part o th e
ch apter th e au th ors ocu s on SSIs a ter ractu re xation ,
join t replacem en t, an d variou s su rgeries o th e orth opedic
an d trau m a spectru m th at in volve solely th e so t tissu e.
Deep SSIs in volvin g th e im plan t are covered in ch apters 4
Preven tion o in traoperative in ection , 9.1 In ection a ter
ractu re, 9.2 In ected n on u n ion , an d 10 In ection a ter join t
arth roplasty.
De fin itio n a n d cla ssifica tio n
Th e de n ition o SSIs u sed by th e British Nosocom ial In ec-
tion Nation al Su rveillan ce System is: A su rgical-site in ec-
tion occu rs w h en m icro-organ ism s get in to th e part o th e
body th at h as been operated on an d m u ltiply in th e tissu e
[5 4]. Th e US Cen ters or Disease Con trol an d Preven tion
de n ition states th at SSI or w ou n d in ection s m ain ly occu r
w ith in th e rst 30 days a ter su rgery an d th ey are categorized
in su per cial in cision al SSI, deep in cision al SSI, an d organ /
space SSI [55]. Su per cial in ection s a ect th e su bcu tan eou s
layers, w h ereas deep in cision al in ection s in clu de th e m u s-
cu lar ascia an d th e m u scle [2, 51].
Etio lo gy a n d m icro b io lo gy
An im portan t risk actor or su bsequ en t w ou n d in ection is
th e exten t o m icrobial con tam in ation at a su rgical site [8].
Th ere ore, operative w ou n ds are classi ed based on m icro-
bial con tam in ation in th e ollow in g categories: clean , clean -
con tam in ated, con tam in ated, an d dirty [56].
Th e m ost requ en t path ogen cau sin g SSI is S aureus; h ow -
ever, th e spectru m o path ogen s varies w ith th e a ected
body region [2, 57].
Clin ica l m a n ife s ta tio n
Su rgical-site in ection s com m on ly presen t w ith local sign s
o in ection , su ch as eryth em a, pain , sw ellin g, an d pu ru len t
drain age, an d can be accom pan ied by ever an d oth er sys-
tem ic sign s o in ection . Early postoperative ever u su ally
arises rom n on in ectiou s or u n kn ow n cau ses an d is u su ally
n ot associated w ith SSI sin ce postoperative w ou n d in ection s
rarely occu r w ith in th e rst 48 h ou rs a ter in cision . Rare
cases o SSIs th at m an i est with in th e rst 2 days a ter su rgery
are gen erally cau sed by S pyogenes an d Clostridium species [2].
Dia gn o sis
Accordin g to th e US practice gu idelin es, SSIs are diagn osed
w ith at least on e o th e ollow in g sym ptom s:
Pu ru len t in cision drain age
Positive cu ltu re o aseptically obtain ed f u id or tissu e
rom th e su per cial w ou n d
Local sign s an d sym ptom s o pain an d ten dern ess,
sw ellin g, an d eryth em a a ter th e in cision is open ed by
a su rgeon (u n less cu ltu re n egative)
Diagn osis o SSI by th e atten din g su rgeon or ph ysician
based on th eir experien ce an d expert opin ion [2]
With in th e UK de n ition su rgeon s' opin ion is n ot u sed as
an in dicator or in ection ; th e presen ce o pu s is u sed in stead
o cu ltu red m icroorgan ism s rom clin ical sam ples [54].
Postoperative ever or system ic sign s o in ection sh ou ld
alw ays lead to a direct exam in ation o th e w ou n d an d be
ollow ed by a test o th e WBC cou n t an d CRP level. Espe-
cially in ever occu rrin g w ith in th e rst ew days, sign s su g-
gestive o in ection du e to S pyogenes an d Clostridium species
m u st be ru led ou t [2].
Nu m erical scorin g system s, su ch as th e Sou th am pton Wou n d
Assessm en t Scale an d ASEPSIS, can h elp to evalu ate th e
severity o SSIs an d to m on itor th e cou rse o th e in ection .
Magn itu de o serou s or pu ru len t exu date, eryth em a, an d
su ppu ration o deep tissu e are u sed to evalu ate th e statu s
o in ection [58, 59].
Sp e cific tre a tm e n t
Early f at eryth em atou s skin ch an ges in th e n ear su rrou n din g
o th e w ou n d w h ich are n ot accom pan ied by sw ellin g or
drain age typically w ill resolve w ith ou t an y speci c th erapy
[2]. Spread o th e eryth em a, w ou n d drain age, an d sw ellin g
in dicate n eed or treatm en t. Th e su rgical debridem en t o
th e in cision to evacu ate th e detritu s an d in ected tissu e is
th e m ost im portan t aspect o th erapy [2]. Th e exten t o local
in ection an d th e presen ce o system ic sign s sh ou ld be
evalu ated care u lly to in itiate th e appropriate su rgical treat-
m en t an d lau n ch adju van t system ic an tim icrobial th erapy.
Adju n ctive system ic an tibiotic th erapy is n ot n ecessary i
eryth em a an d in du ration is less th an 5 cm an d i th e patien t
255
 Se ct io n 2Spe cial
situations
13
Soft-tissue
infe ctions
h as m in im al system ic sign s o in ection (ie, tem peratu re
< 38.5 C; WBC cou n t < 12,000 cells/ L, an d pu lse rate < 100
beats/ m in u te) [2, 60]. Especially in su bcu tan eou s abscesses,
variou s stu dies cou ld n ot prove a relevan t ben e t or adju -
van t an tim icrobial th erapy w h en com bin ed w ith su rgical
drain age [2, 61, 62]. Com plem en tary proph ylactic an tibiotics
are n ot in dicated sin ce in cision an d su rgical debridem en t o
su per cial abscesses rarely cau ses bacterem ia [63]. An ery-
th em a exceedin g 5 cm beyon d th e su rgical in cision or a
system ic in f am m atory respon se w ith h igh ever (> 38.5 C)
or pu lse rate (> 110 beats/ m in u te) requ ire addition al th er-
apytypically a sh ort cou rse o an tim icrobial th erapy. In
th e case o a proven MRSA in ection or n asal colon ization
or i th e patien t h ad a prior MRSA in ection , an tim icrobial
th erapy sh ou ld in clu de van com ycin , daptom ycin , lin ezolid,
telavan cin , or ce tarolin e [2]. Em piric an tibiotic th erapy in
SSI ollow in g su rgery o in testin al or gen itou rin ary tract
sh ou ld cover gram -n egative an d an aerobic path ogen s. See
ch apter 5 System ic an tibiotics, Ta b le 5-1 an d Ta b le 5-2 or
details on an tibiotic th erapy.
Pre ve n tio n
Su rgical-site in ection s are associated with in creased m orbid-
ity an d m ortality an d pose a h igh econ om ic bu rden on th e
h ealth care system [6 4 ]. Addition ally, th e em ergen ce o
an tibiotic resistan ce h as been observed over th e last th ree
decades [57]. Th ere ore, preven tion o SSIs by system ch an g-
es, su rveillan ce, an d edu cation is o particu lar im portan ce
[65]. Th e preven tion o perioperative in ection s or m ost su r-
geries in trau m a care an d orth opedics is discu ssed in detail
in ch apter 4 Preven tion o in traoperative in ection [6567].
2 .6 .2 Wo u n d in fe ctio n a fte r tra u m a
Skin an d so t tissu e can be trau m atized by blu n t or pen etrat-
in g orce, th erm ally, ch em ically, or by radiation . Trau m a
can lead to con tam in ation o th e in ju red tissu e an d su bse-
qu en t developm en t o a w ou n d in ection . Th e cau se as w ell
as th e exten t o trau m a, th e body site, an d th e h ost im m u n e
statu s all play a critical role in th e developm en t o w ou n d
in ection . Misu n derstan din g o trau m a can resu lt in in ap-
propriate m an agem en t, su ch as m issed an tibiotic proph y-
laxis. Th e m ost com m on w ou n d in ection s are related to
pen etratin g so t-tissu e trau m a (in clu din g bu rn an d bite
in ju ries).
Gen erally, wou n d in ection s are treated accordin g to th e treat-
m en t prin ciples o SSIs. Th ere are di eren t treatm en t recom -
m en dation s or in ection s ollow in g m am m alian or h u m an
bites. Th ese speci c problem s are discu ssed separately.
256
In every open in ju ry, th e tetan u s vaccin ation statu s o th e
patien t m u st be validated. A tetan u s toxoid booster sh ou ld
be adm in istered to patien ts w ith an u n kn ow n vaccin ation
statu s or in com plete vaccin ation series or clean w ou n ds i
m ore th an 5 years elapsed sin ce th e last dose an d or dirty
w ou n ds i 5 years h ave passed [2].
An im a l a n d h u m a n b ite w o u n d s
Mam m alian bites are m ost com m on ly cau sed by dogs or
cats an d are colon ized by m icroorgan ism s ou n d in th e
an im als oral cavity. Th e m u ltim icrobial f ora is a m ixtu re
o aerobic an d an aerobic path ogen s in clu din g streptococci,
staph ylococci, Moxarella, Neisseria, Fusobacterium, Bacteroides,
an d Pasteurella species, a com m on gram -n egative bacteriu m
in cats an d dogs [68]. Patien ts w ith an im al bites in areas w ith
h igh prevalen ce o rabies sh ou ld be con sidered or rabies
vaccin ation accordin g to region al recom m en dation s [2]. It
sh ou ld be con sidered th at bites cau sed by bats also pose a
h igh risk o rabies tran sm ission .
Hu m an bites resu lt in bacterial con tam in ation w ith both
aerobic an d an aerobic path ogen s, th e risk o tran sm ittin g
HIV or h epatitis B/ C. Patien ts sh ou ld be treated w ith an ti-
biotic proph ylaxis an d possible viral tran sm ission .
Tre a tm e n t p rin cip le s a fte r b ite tra u m a
Basic prin ciples in clu de both appropriate su rgical th erapy
an d an tim icrobial proph ylaxis. Early an tim icrobial proph y-
laxis or 35 days sh ou ld be adm in istered an d is recom -
m en ded in th e ollow in g circu m stan ces:
All cat bites
Moderate or severe in ju ries, especially to ace an d h an d
In ju ries th at m ay h ave pen etrated th e periosteu m or
join t capsu le
Im m u n ocom prom ised patien ts
Preexistin g or developin g edem a o a ected body area
[2]
Su rgical debridem en t an d irrigation o th e bite w ou n d sh ou ld
be con sidered. Prim ary w ou n d closu re is solely recom m en d-
ed or w ou n ds to th e ace [2]. Tem porary NPWT is an option
to en su re w ou n d drain age an d en able a secon d-look su rgery.
Major so t-tissu e de ects or sign i can t so t-tissu e sw ellin g
th at preven ts prim ary w ou n d closu re can be covered by
NPWT. Local an tibiotics u sed or bite w ou n ds lack th e lit-
eratu re su pport an d th u s th is option is n ot recom m en ded.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Sve n Hungere r, Mario Morge nstern
Tre a tm e n t p rin cip le s in in fe ctio n a fte r b ite tra u m a
Am oxicillin -clavu lan ate, an an tim icrobial agen t active
again st aerobic an d an aerobic bacteria is th e rst ch oice oral
th erapy in in ected an im al bite w ou n ds [2]. Oth er treatm en t
option s w ith aerobic coverage are secon d- or th ird-gen er-
ation ceph alosporin s (IV u sage), levof oxacin , or trim e-
th oprim -su l am eth oxazole, w h ich sh ou ld be accom pan ied
by an aerobic coverage w ith clin dam ycin or m etron idazole.
Moxif oxacin is an altern ative th erapy [2]. Su rgical th erapy
is in dicated accordin g to th e treatm en t gu idelin es or SSTIs
based on local an d system ic actors.
2 .7 Ne cro t izin g s o ft-t is s u e in fe ct io n s
2 .7.1 De fin itio n
Necrotizin g so t-tissu e in ection s are ch aracterized by th e
n ecrosis o skin an d su bcu tan eou s tissu e (ie, n ecrotizin g
cellu litis), ascia (ie, n ecrotizin g asciitis), an d u n derlyin g
m u scle (ie, m yon ecrosis), or com bin ation s o th ese n din gs
[6 9 ]. Necrotizin g so t-tissu e in ection s are rare bacterial
in ection s w ith an in ciden ce o 0.40.5 cases per 100,000
people [7 0 7 2 ]. Th ey can presen t in com bin ation w ith a
u lm in an t an d li e-th reaten in g septic cou rse, su ch as th e
n ecrotizin g asciitis. Th ey di er con siderably rom su per cial
in ection s by clin ical presen tation an d cou rse, coexistin g
system ic m an i estation , an d treatm en t strategies [7 3, 7 4].
Necrotizin g so t-tissu e in ection s are cross-layer in ection s
w ith a possible in volvem en t o th e ascia an d th e m u scle
com partm en ts, w h ich lead to a n ecrosis o th e a ected
tissu e. Th ey w ere rst described in 1871 by Jon es an d term ed
h ospital gan gren e [70]. In 1952 Wilson described n ecrotiz-
in g asciitis as a ectin g th e ascia an d su bcu tan eou s tissu e
[75]. Sin ce th en m u ltiple description s an d classi cation s o
NSTIs w ere pu blish ed, w h ich led to som e con u sion . Th ere-
ore, on e m u st em ph asize th at de n in g th e speci c varian t
is o secon dary im portan ce an d th at NSTIs h ave com m on
path oph ysiological an d clin ical m an i estation w ith th e sam e
prin ciples or diagn osis an d treatm en t [76, 77].
2 .7.2 Etio lo g y a n d m icro b io lo gy
An NSTI typically develops a ter in ju ry to th e in volved site
en ablin g bacteria to breach th e skin barrier [5]. Necrotizin g
asciitis m ay be associated w ith an y trau m a or in cision to
th e skin in clu din g m in or lesion s, su ch as in sect bites an d
in jection sites [78, 79]. In 2045% o th e cases, n o de n itive
access poin t can be ou n d becau se th ese m in or lesion s are
o ten orgotten or obscu re [5, 80 ]. An y im pairm en t o th e
h ost im m u n e system , obesity, an d th e risk actors listed in
Ta b le 13 -2 predispose to NSTI, alth ou gh h al o th e cases
occu r in previou sly h ealth y in dividu als [81, 82].
Disease-cau sin g path ogen s can be aerobic, an aerobic, gram
positive an d gram n egative, or even u n gal species [5, 7, 8].
Con siderin g th e in ectin g path ogen , th e Giu lian o Classi ca-
tion de n es tw o types o n ecrotizin g asciitis [83]:
Type I: syn ergistic actin g an aerobic-aerobic m ixed in ection s
Type II: grou p A streptococci possibly com bin ed w ith S au-
reus or Staphylococcus epidermidis
Th e Giu lian o Classi cation h as n o im pact on th e clin ical
diagn osis or th erapy. Type I asciitis is reported to be less
aggressive in th e clin ical cou rse th an type II w ith S pyogenes
(grou p A streptococci) as cau sative bacteria.
2 .7.3 Clin ica l m a n ife s ta tio n s
Th e in itial stage o th e n ecrotizin g asciitis lacks m ajor cu -
tan eou s sign s an d resem bles a cellu litis, w h ich is gen erally
treated n on operatively w ith an tibiotics [5, 7 , 8]. In patien ts
believed to h ave cellu litis, th e triad o sw ellin g, eryth em a
( Fig 13-5 ), an d disproportion ately severe pain o ten precedes
skin n din gs, an d sh ou ld raise su spicion o n ecrotizin g as-
ciitis [84]. An oth er clu e o a deeper an d devastatin g in ection
is th e rapid spread o eryth em a, despite system ic an tibiotic
th erapy [85]. As it progresses, w arm th an d in du ration o th e
skin w ith a w oody eelin g o th e su bcu tan eou s tissu es de-
velops. Palpation perm its discrim in ation rom cellu litis an d
erysipelas. In su per cial in ection s, su bcu tan eou s tissu es
can be palpated an d are yieldin g in asciitis [5, 78 ]. In th e
advan ced stages, classic sign s o a n ecrotizin g in ection o
th e skin an d deeper layers develop (see ch apter 5 System ic
an tibiotics, Ta b le 5 -1 an d Ta b le 5 -2 ). Here a prim ary stage to
skin n ecrosis ( Fig 13 -6 ) is o ten an u n dem arcated m arm o-
rated skin w ith blisters an d bu llae, w h ich are drain in g
Fig 13-6 Advance d stage of ne crotizing
soft-tissue infe ction with skin ne crosis.
Surge ry re ve als pus drainage and con rm s
diagnosis.
257
 Se ct io n 2Spe cial
situations
13
Soft-tissue
infe ctions
serosan gu in ou s an d later h em orrh agic f u id ( Fig 13 -7 ). Th ese
are accom pan ied by sign s o system ic in ection : ever, h y-
poten sion , tach ycardia, an d altered con sciou sn ess [86]. Re-
qu irin g adm ission to an in ten sive care u n it, th e critically ill
patien t can develop m u ltiorgan ailu re w ith acu te ren al
ailu re (35% ), coagu lopath y (29% ), liver dys u n ction (28% ),
an d acu te respiratory distress syn drom e (14% ) [87 ]. It is
essen tial to n ot m iss th e diagn osis o NSTI becau se in itially
classic skin n din gs are n ot presen t an d n ot all patien ts sh ow
a system ic sym ptom , su ch as ever [88]. Th e m ost sen sitive
diagn ostic sym ptom , w h ich is presen t in n early 100% o
cases, is th e disproportion ately severe pain [89].
Fig 13-7 Advance d stage of ne crotizing soft-tissue infe ction:
unde m arcate d subcutane ous he m orrhage and infe ction
accom panie d by draining bullae and bliste rs with are as of be ginning
skin ne crosis.
a in g in f am m ation an d lym ph n ode a ection . Th e vital sign s
b Crepitus (indicating gas in the soft tissue)
Fig 13-8 a b Initial and pre ope rative skin ndings ofte n do not
re pre se nt the e xte nt of the unde rlying infe ction.
258
2 .7.4 Dia gn o sis
Th e diagn osis o NSTI is prim arily a clin ical diagn osis con -
siderin g th e patien ts sym ptom s an d clin ical cou rse, risk
actors, an d th e local skin lesion s. Clin ical ju dgm en t is th e
m ost im portan t actor w h en diagn osin g NSTI. Th e n ext step
a ter clin ical diagn osis o NSTI is th e im m ediate radical
su rgical debridem en t o th e a ected so t tissu es to redu ce
m orbidity an d m ortality [26 ].
Du e to th e trem en dou s con sequ en ces or th e patien ts
clin ical ou tcom e an d du e to legal con sideration s, in -person
evalu ation is th e key elem en t an d th is diagn osis sh ou ld be
m ade by at least tw o ph ysician s or su rgeon s. An y oth er op-
tion s or diagn osis o NSTIs sh ou ld n ot delay th e su rgical
th erapy.
Th e early clin ical diagn osis is di cu lt becau se o th e in itial
absen ce o system ic sign s o in ection . In th e early ph ase,
th e m in or skin lesion s appear w h ich m ay resem ble cellu li-
tis ( Fig 13-8 ) [2]. A h igh in dex o su spicion is critical an d is
th e m ost im portan t actor in early diagn osis o NSTIs. Con -
sequ en tly, laboratory an d x-ray exam in ation s sh ou ld be
added to su pport early diagn osis bu t sh ou ld n ever delay
su rgical in terven tion [78, 90].
Histo ry a n d e xa m in a tio n
In itially, th e diagn osis begin s w ith a m edical h istory an d
detailed exam in ation . Th e classic sign s o NSTIs sh ou ld raise
su spicion an d in orm th e diagn osis o NSTI ( Ta b le 13 -3 ). Risk
actors sh ou ld be determ in ed ( Ta b le 13-2 ). In patien ts w ith
IV/ su bcu tan eou s dru g abu se an d ch ron ic debilitatin g dis-
eases, it is im portan t to su spect NSTI [7 7 ]. A com plete
clin ical exam in ation can detect th e above-m en tion ed skin
m an i estation s, su ch as a possible skin lesion or or m igrat-
as w ell as th e m en tal statu s are also im portan t n din gs [2].
Signs o necrotizing so t-tissue in ections
Severe constant pain (disproportionate to injury or clinical presentation)
Blisters and bullae (draining serosanguineous and later hemorrhagic fluid)
Skin necrosis (preceded by violaceous discoloration)
Superficial fat and fascia necrosis (often foul-smelling)
Edema (extending beyond the erythema)
Cutaneous anesthesia
Woody feeling of subcutaneous tissues
Signs of systemic toxicity
Rapid progression (despite antibiotic therapy)
Ta b le 13-3 Classic signs of ne crotizing soft-tissue infe ctions.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Sve n Hungere r, Mario Morge nstern
Ra d io lo gica l e va lu a tio n
Plain x-rays m ay detect gas in th e so t tissu e. Th e diagn ostic
valu e is low becau se gas produ ction occu rs in advan ced
stages an d is rarely presen t early on [78]. Im agin g by CT or
MRI can sh ow edem a exten din g alon g th e ascial plan e, bu t
th e sen sitivity an d speci city are low . Ultrasou n d is qu ick
an d im m ediately available. I epi ascial f u id is detected,
su rgical exploration is m an datory.
La b o ra to ry fin d in gs
Im portan t laboratory n din gs are sepsis param eters, su ch
as leu kocytosis, leu kopen ia, an d in crease o CRP, procal-
citon in , or in terleu kin -6. Procalciton in is su itable to assess
th e su ccess o su rgical debridem en t by calcu latin g th e
preoperative/ postoperative ratio [91].
Fish er et al [9 2 ] de n ed ve criteria or th e diagn osis o
n ecrotizin g asciitis:
Moderate to severe system ic toxic reaction
Absen ce o m ajor vascu lar occlu sion
Su rgical site: exten sive n ecrosis o th e ascia u n derm in -
in g th e su rrou n din g tissu e an d absen ce o prim ary
m u scle in volvem en t ( Fig 13 -9 )
Microbiology: ailu re to dem on strate clostridia
Histology: leu kocyte in ltration , ocal ascia n ecrosis,
an d n ecrosis o th e su rrou n din g tissu e, m icrovascu lar
th rom bosis
On ly th e rst tw o criteria are su itable or th e im m ediate
diagn osis o NSTI, respective o n ecrotizin g asciitis. All
oth er criteria are on ly u se u l i su rgery h as already been
per orm ed: assessm en t o asciitis, m yositis, m icrobiology,
or h istology. Th ese resu lts can on ly con rm th e diagn osis
o NSTI an d are th ere ore n ot u se u l param eters in decision
m akin g ( Fig 13-9 ).
2 .7.5 Diffe re n tia l d ia gn o sis
Ce llu litis
Th e crossover rom cellu litis to NSTIs is rapid, an d th is is
th e ch allen ge. Th e treatm en t o cellu litis is n on operative
w ith an tibiotics, im m obilization , an d local an tiseptic dress-
in g. A clin ical cou rse w ith rapid deterioration o th e patien ts
con dition m u st raise su spicion or th e diagn osis o NSTI an d
su rgical exploration sh ou ld be th e n ext step.
Ga s ga n gre n e
Gas gan gren e is an oth er li e-th reatin g in ection o th e so t
tissu e o ten in volvin g th e m u scles. Gas gan gren e is cau sed
by Clostridium per ringens or Bacillus species. Th e typical
clin ical n din gs are th e crepitation o skin an d so t tissu es
an d th e in itial h igh pain levels. Th e skin appears to be m ore
livid. In traoperative n din gs are bu bbles in w ou n d secretion
an d raspberry-like n ecrosis o th e m u scles.
P yo d e rm a ga n gre n o su m
Pyoderm a gan gren osu m (PG) is an au toim m u n e disease
th at som etim es m im ics n ecrotizin g asciitis to a strikin g
degree [93]. Th is can be in du ced by trau m a or su rgery; th e
clin ical eatu res are pu ru len t n ecrosis o skin , su bcu tan eou s
tissu e, an d ascia w ith ou t m icrobiological n din gs. It is a
diagn osis by exclu sion an d th is is essen tial to treat PG. Treat-
m en t or PG is th e diam etric opposite to NSTIs. On ce PG is
su spected, im m u n osu ppression w ith h igh -dose cortisol or
m eth otrexate is th e th erapy o ch oice. An y u rth er su rgery
sh ou ld be avoided or m in im ized.
Gra m -p o sitive to xic sh o ck s yn d ro m e
Gram -positive toxic sh ock syn drom e (TSS) is an acu te,
toxin -in du ced septic sh ock syn drom e ch aracterized by h y-
poten sion [94]. Cau sative agen ts are streptococci or staph y-
lococci produ cin g a su peran tigen (eg, TSST-1). On e clin ical
criterion or th e diagn osis o TSS is so t-tissu e n ecrosis.
Fig 13-9 Surge ry re ve als ne crotic fascia
and subcutane ous fat; the incision m ust
be e xpande d until no m ore pus drainage
or ne crosis is de te cte d.
259
 Se ct io n 2Spe cial
situations
13
Soft-tissue
infe ctions

2 .7.6 Sp e cific tre a tm e n t For tem porary wou n d closu re an d con dition in g o so t tissu es,
Th e treatm en t or NSTIs w ith acu te septic in f am m atory NPWT is su itable. Th e NPWT sim pli es th e f u id m an age-
reaction is based on a th ree-pillar strategy: m en t o th e patien t. It provides an aseptic w ou n d closu re
even or large w ou n ds or w h ole extrem ities or a ter partial
1. Radical su rgical debridem en t: su rgical debridem en t is skin rem oval rom th e tru n k ( Fig 13-3 ).
th e prim ary th erapeu tic m odality an d in clu des
resection o n ecrotic skin , su bcu tan eou s tissu e, an d An adju van t th erapy option is h yperbaric oxygen th erapy
ascia. Th e prim ary aim is th e redu ction o bacterial [2 1 ]. Even th ou gh th ere is little eviden ce or h yperbaric
an d in f am m atory load. Th e resection o all a ected oxygen th erapy in th e treatm en t o NSTIs in con trast to gas
tissu e sh ou ld create a re lin e to avoid progression gan gren e, it sh ou ld be con sidered or patien ts w ith n ecrotiz-
o th e process to th e tru n k. Th e progn osis or th e in g STIs bu t it sh ou ld n ever delay su rgical th erapy [9597].
patien t decreases rapidly i th e tru n k is a ected. Li e
be ore lim b: am pu tation or li e-th reatin g in ection s 2 .7.7 Pro gn o sis
w ith circu m eren tially a ected lim bs is n ecessary in Even w ith optim al th erapy, NSTI is associated w ith a h igh
3050% o cases. A secon d-look operation is m an da- m ortality ran gin g rom 21.4% to 50% [70].
tory a ter 1236 h ou rs depen din g on th e clin ical
cou rse. Th e patien t sh ou ld retu rn accordin g to
system ic an d local statu s to th e operatin g room on
regu lar in tervals [2]. Sm all in cision s an d in appropriate
w ou n d coverage sh ou ld be avoided becau se su cien t
drain age is n ot possible an d local in ection can
progress ( Fig 13 -10 ).
2. Early h igh -dose an tibiotic th erapy: cu rren t recom m en - a
dation s or em piric an tibiotic treatm en t sh ou ld in clu de
agen ts active again st both aerobes in clu din g MRSA
an d an aerobes [2]. Th e treatm en t recom m en dation s
are su m m arized in Fig 13-11 . Th e recom m en dation s or
th e US con sider a h igh prevalen ce o MRSA an d are
design ed to cover m eth icillin -resistan t staph ylococci. b
Th is su ggestion sh ou ld be applied in region s w ith a
Fig 13-10 a b Radical de bride m e nt in ne crotizing soft-tissue
h igh -MRSA prevalen ce. Recom m en dation s or low infe ctions: limite d incisions should be avoide d to guarante e
MRSA in ection rates are adapted rom th e Germ an appropriate drainage .
Pau l-Eh rlich Society o Ch em oth erapy gu idelin es. As
soon as a m icrobial cau se h as been determ in ed an d
su sceptibility testin g is available, an tibiotic th erapy
sh ou ld be reevalu ated an d targeted w ith th e assistan ce
o an in ectiou s diseases specialist. Recom m en dation s
or path ogen -gu ided an tim icrobials are listed in
Fig 13 -11 . An tibiotics sh ou ld be given u n til su rgical
treatm en t is com pleted an d n o addition al debridem en t
is n ecessary, th e patien t h as im proved clin ically, an d
ever h as been absen t or 4872 h ou rs [2].
3. In ten sive care u n it m on itorin g an d treatm en t o
m u ltiorgan ailu re an d f u id m an agem en t.

260 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Sve n Hungere r, Mario Morge nstern

Empiric antibiotic therapy or NSTI:

Agent group 1 Agent group 2

Acylamino-PEN/BLI (PIP-TAZ) or
Yes Vancomycin or
Carbapenem or
Linezolid or + Ceftriaxone (Ceph.3a) and metronidazole or
Daptomycin
Empiric Fluoroquinolone and metronidazole
US and regions
antibiotic
with MRSAprevalence
therapy Acylamino-PEN/BLI (PIP-TAZ) or
Carbapenem or
Clindamycin + Ceph. 3a* (eg, ceftriaxone) or
No
Moxifloxacin

Calculated antibiotic therapy or NSTI

Pathogen Agent group 1 Agent group 2

Vancomycin or
Acylamino-PEN/BLI (PIP-TAZ)
+ Carbapenem
Mixed in ections
Clindamycin or
Cefotaxime (Ceph. 3a) + Metronidazole

Streptococcus spp. Penicillin + Clindamycin

Nafcillin
Oxacillin or
Staphylococcus aureus Cefazolin (Ceph. 1) or
Clindamycin or
Vancomycin (for resistant strains)

Clostridium spp. Penicillin + Clindamycin

Fig 13-11 Antibiotic tre atm e nt of ne crotizing soft-tissue infe ctions adapte d from IDSA Guide line s 2014 with Europe an re com m e ndations.
The se are curre ntly re com m e nde d in the US but tre atm e nt options will vary base d on the location of the re ade r.
*
Em piric antibiotic the rapy for NSTI in re gions with low MRSA pre vale nce: third-ge ne ration ce phalosporin can be also com bine d with
me tronidazole ( inste ad of clindam ycin).

Moxi oxacin can be also com bine d with line zolid ( inste ad of clindamycin).
Abbre viations: MRSA, m e thicillin-re sistant Sta phylococcus a ure us; acylam ino-PEN/ BLI, acylam ino -pe nicillin with a -lactam ase inhibitor;
PIP-TAZ, pipe racilin tazobactam; Ce ph.3a, third-ge ne ration ce phalosporin; Ce ph.1, rst-ge ne ration ce phalosporin; spp., spe cie s.

261
 Se ct io n 2Spe cial
situations
13
Soft-tissue
infe ctions
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in ection s. In ect Dis Clin North Am. 1992
Sep;6(3):693 703.
75. Wils o n B. Necrotizin g asciitis. Am Surg.
1952 Apr;18(4):416 431.
76. De llin ge r EP. Severe n ecrotizin g
so t-tissu e in ection s. Mu ltiple d isease
en tities requ irin g a com m on approach .
JA MA. 1981 Oct 9;246(15):17171721.
77. An a ya DA, De llin ge r EP. Necrotizin g
so t-tissu e in ection : d iagn osis an d
m an agem en t. Clin In ect Dis. 20 07 Mar
1;4 4(5):705 710.
78. Be lla p ia n t a JM, Lju n gq u is t K, To b in E,
e t a l. Necrotizin g asciitis. J Am Acad
Orthop Surg. 2009 Mar;17(3):174 182.
79. Frie d e rich s J, To rka S, Milit z M, e t a l.
Necrotizin g so t tissu e in ection s a ter
in jection th erapy: High er m ortality an d
worse ou tcom e com pared to oth er
en tr y m ech an ism s. J In ect. 2015
Sep;71(3):312 316.
80. Mu lla ZD. Treatm en t option s in th e
m an agem en t o n ecrotisin g asciitis
cau sed by Grou p A Streptococcu s.
Expert Opinion Pharmacother. 200 4
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81. Du fe l S, Ma r t in o M. Sim ple cellu litis or
a m ore seriou s in ection ? J Fam Pract.
2006 May;55(5):396 4 0 0.
82. Go h T, Go h LG, An g CH, e t a l. Early
diagn osis o n ecrotizin g asciitis.
Br J Surg. 2014 Jan ;101(1):e119 125.
83. Giu lia n o A, Le w is F Jr, Ha d le y K, e t a l.
Bacteriology o n ecrotizin g asciitis. Am
J Surg. 1977 Ju l;134(1):5257.
8 4. Sim o n a r t T. Grou p a beta-h aem olytic
streptococcal n ecrotisin g asciitis: early
diagn osis an d clin ical eatu res.
Dermatology. 20 04;208(1):5 9.
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infe ctions

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Necrotizin g asciitis: clin ical
presen tation , m icrobiology, an d
determ in an ts o m ortality. J Bone Joint
Surg Am. 2003 Au g;85-A(8):1454 1460.
86. Kih icza k GG, Sch w a rt z RA, Ka p ila R.
Necrotizin g asciitis: a dead ly in ection .
J Eur Acad Dermatol Venereol. 2006
Apr;20(4):365 369.
87. Ka u l R, McGe e r A, Lo w DE, e t a l.
Popu lation -based su rveillan ce or grou p
A streptococcal n ecrotizin g asciitis:
clin ical eatu res, progn ostic in dicators,
an d m icrobiologic an alysis o seven ty-
seven cases. On tario Grou p A
Streptococcal Stu dy. Am J
Med.1997;103(1):18 24.
88. Ro d rigu e z RM, Ab d u lla h R, Mille r R,
e t a l. A pilot stu dy o cytok in e levels
an d wh ite blood cell cou n ts in th e
d iagn osis o n ecrotizin g asciitis.
Am J Emerg Med. 20 06 Jan ;24(1):58 61.
89. Yo u n g MH, Aro n o ff DM, En gle b e rg NC.
Necrotizin g asciitis: path ogen esis an d
treatm en t. Exp Rev Anti In ect Ther. 20 05
Apr;3(2):279 294.
90. Wo n g CH, Wa n g YS. Th e diagn osis o
n ecrotizin g asciitis. Curr Opin In ect Dis.
2005 Apr;18(2):101106.
91. Frie d e rich s J, Hu t t e r M, Hie rh o lze r C,
e t a l. Procalciton in ratio as a pred ictor
o su ccess u l su rgical treatm en t o
severe n ecrotizin g so t tissu e in ection s.
Am J Surg. 2013 Sep;206(3):368 373.
92. Fis h e r JR, Co n w a y MJ, Ta ke s h it a RT,
e t a l. Necrotizin g asciitis. Im portan ce
o roen tgen ograph ic stu d ies or
so t-tissu e gas. JA MA. 1979 Feb
23;241(8):803 806.
93. Bro o klyn T, Du n n ill G, Pro b e r t C.
Diagn osis an d treatm en t o pyoderm a
gan gren osu m . BMJ. 2006 Ju l
22;333(7560):181184.
94. La p p in E, Fe rgu s o n AJ. Gram -positive
toxic sh ock syn drom es. Lancet In ect Dis.
2009 May;9(5):281290.
95. Willy C, Rie ge r H, Vo gt D. [ Hyperbaric
oxygen th erapy or n ecrotizin g so t
tissu e in ection s: con tra]. Chirurg. 2012
Nov;83(11):960 972. Germ an .
96. Ed lich RF, Cro s s CL, Da h ls t ro m JJ, e t a l.
Modern con cepts o th e diagn osis an d
treatm en t o n ecrotizin g asciitis.
J Emerg Med. 2010 Au g;39(2):261265.
97. Ma s s e y PR, Sa k ra n JV, Mills AM, e t a l.
Hyperbaric oxygen th erapy in
n ecrotizin g so t tissu e in ection s.
J Surg Res. 2012 Sep;177(1):14 6 151.

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Jorge Danie l Barla, Luciano Rossi, Yoav Rosenthal, Ste ve n Ve lke s
14 Op e n w o u n d s
Jorge Danie l Barla, Lu cian o Ro ssi, Yo av Rose n th al, Ste ve n Ve lke s
1 Ba s ics
A wou n d is a disru ption o th e n orm al stru ctu re an d u n ction
o th e skin an d u n derlyin g so t tissu e [1 ]. Wou n ds are
gen erally classi ied as acu te or ch ron ic. Acu te w ou n ds
n orm ally h eal th rou gh an orderly sequ en ce o ph ysiological
even ts th at in clu de h em ostasis, in f am m ation , epith elialization ,
broplasia, an d m atu ration [2]. Wh en th is process is altered,
im peded, or delayed, a ch ron ic w ou n d m ay develop.
1.1 Ph a s e s o f w o u n d h e a lin g
1.1.1 In fla m m a tio n
Th is ph ase is ch aracterized by in creased vascu lar perm eabil-
ity an d cellu lar recru itm en t. Macroph ages an d strom al m ast
cells release vasoactive su bstan ces th at stim u late th e ch e-
m otaxis o m acroph ages an d polym orph on u clear leu kocytes
th at digest bacteria, oreign debris, an d n ecrotic tissu e [3].
Th e h ealin g progression o ch ron ic w ou n ds is u su ally ar-
rested in th is in f am m atory stage.
1.1.2 Migra tio n
Migration or epith elialization re ers to basal cell proli eration
an d epith elial m igration occu rrin g in th e brin bridgew ork
in side a clot [4]. Migration ceases w h en th e layer is replaced;
th is is n orm ally com pleted w ith in 48 h ou rs o su rgery. Th e
su per cial layer o epith eliu m orm s a barrier to bacteria
an d oth er oreign bodies. Th e process o epith elialization is
di cu lt in w ou n ds th at are n ot prim arily closed, an d m ay
in stead h eal by secon dary in ten tion . In th ese w ou n ds, th e
ph ysical distan ce o epith elial m igration is in creased across
th e len gth an d w idth an d depth o th e w ou n d.
1.1.3 Fib ro p la sia
Fibroplasia con sists o broblast proli eration , accu m u lation
o grou n d su bstan ce, an d collagen produ ction [5].
Fibroblasts also syn th esize collagen , th e prim ary stru ctu ral
protein o th e body. Maxim u m collagen produ ction begin s
on day 5 an d con tin u es or at least 6 w eeks [6]. Th e develop-
in g collagen m atrix stim u lates an giogen esis. Gran u lation
tissu e is th e resu lt o th e com bin ed produ ction o collagen
an d grow th o capillaries. Th is exu beran t scarrin g m ay
im pede n orm al organ u n ction or, in th e case o skin , m ay
resu lt in keloid orm ation .
1.1.4 Ma tu ra tio n
Key elem en ts o m atu ration in clu de collagen cross-lin kin g,
collagen rem odelin g, w ou n d con traction , an d repigm en ta-
tion . As disorgan ized collagen is degraded an d re orm ed,
covalen t cross-lin ks are orm ed th at en h an ce ten sile stren gth
[7].
1.2 Co m p lica t io n s in w o u n d h e a lin g
Follow in g in itial su ccess u l su rgical skin closu re, w ou n d
deh iscen ce m ay resu lt rom disru ption o th e su tu red skin ,
w h ich can be du e to tech n ical error, in ju ry, in ection , or
th e presen ce o oreign m aterial w ith in th e w ou n d.
1.3 Ris k fa ct o rs fo r n o n h e a lin g
Th ere are m an y actors described th at can a ect w ou n d
h ealin g ( Ta b le 14 -1 ) [8 1 1]. Th e m ost com m on n on h ealin g
w ou n ds a ectin g th e low er extrem ities are associated w ith
periph eral artery disease, diabetes, an d ch ron ic ven ou s in -
su cien cy [8, 9].
265
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situations
14
O pe n
wounds

2 Clin ica l a s s e s s m e n t Sym ptom s an d sign s th at cou ld su ggest th e presen ce o sig-

n i can t in ection an d th e n eed or h ospitalization , in traven ou s
An y patien t w ith a w ou n d or u lceration sh ou ld u n dergo a an tibiotics, an d debridem en t treatm en t in clu de:
com plete m edical h istory an d ph ysical exam in ation . Wou n d
assessm en t sh ou ld in clu de: In du ration , cellu litis exten din g > 2 cm beyon d th e
w ou n d m argin s
Location an d n u m ber o w ou n ds In creased local tem peratu re
Len gth , w idth , depth , an d color Pain on palpation an d drain age rom th e site
Presen ce o cellu litis an d drain age In creasin g eryth em a/ cellu litis o th e su rrou n din g skin
Lym ph an gitis
In crease in th e size o th e u lcer
Large am ou n t o drain age
Fever

A th orou gh vascu lar exam in ation sh ou ld be per orm ed,

Risk actor Mechanism o action
Peripheral artery Microvascular obstruction decreases arterial blood flow and
disease diminishes the delivery of oxygen and nutrients to the tissues, and
impairs removal of metabolic waste products [9, 10 ].
Diabetes Multifactorial: vasculopathy, neuropathy, and immunopathy [9 ].
Chronic venous Congestion and pooling of blood in the superficial veins leads
insufficiency to venous hypertension which, if sustained, is associated with
histological changes in the vein wall [12].
Aging The supply of cutaneous nerves and blood vessels decreases with
age, in addition to a general thinning of tissue including dermis
and basement membrane. There is a loss of collagen and reduced
ability to produce more collagen [13, 14 ].
Immunosuppressive Systemic immunosuppression is a risk factor for peripheral wound
therapy delay and nonhealing wounds [15, 16 ].
Sickle cell disease Caused by dysmorphic red blood cells physically occluding small
vessels and vascular shunting [17].
Chemotherapy Detrimental effect on wound healing, specifically through its
effects on vascular endothelial growth factor (VEGF) [19].
Radiation therapy Irradiated skin in the chronic stage is thin, hypovascular, extremely
painful, and easily injured by slight trauma or infection [20].
Spinal cord disease Typically pressure sores, occurring in areas of bony prominence,
and immobilization such as the sacrum, knees, ankle malleoli, and heels [21 ].
Malnutrition Prealbumin and albumin should be obtained from patients with
nonhealing wounds [2 2].
Infection Bacteria produce inflammatory mediators that inhibit
the inflammatory phase of wound healing and prevent
epithelialization [2 3].
Smoking and nicotine Multifactorial with mechanisms that include vasoconstriction
replacement therapy causing a relative ischemia of operated tissues, a reduced
inflammatory response, impaired bactericidal mechanisms, and
alterations of collagen metabolism [24].
Ta b le 14 -1 Risk factors for nonhe aling.
in clu din g palpation o th e radial, em oral, an d pedal pu lses.
Sign s o arterial obstru ction in clu de lack o periph eral pu lses
w ith poor capillary re ll, th in atroph ic skin , an d h ypertro-
ph ic de orm ed n ails.
Non in vasive diagn ostic option s or arterial assessm en t in -
clu de th e an kle-brach ial in dex (resu lts .9 represen t abn orm al
n din gs) an d Du plex u ltrason ograph y. Non in vasive vascu lar
testin g sh ou ld be per orm ed in patien ts w h o presen t w ith
a w ou n d an d h ave an abn orm al pu lse exam in ation , an d
patien ts w ith a n on h ealin g extrem ity w ou n d or u lcer.
2 .1 La b o ra t o r y w o rk u p
Rou tin e laboratory stu dies are per orm ed to evalu ate or
active in ection , an em ia, n u trition al statu s, an d m edical
con dition s th at place th e patien t at risk or n on h ealin g
w ou n ds ( Ta b le 14 -1 ):
Com plete blood cou n t an d di eren tial
Metabolic pan el, liver u n ction tests, albu m in , prealbu -
m in , h em oglobin A1c
Prealbu m in an d albu m in are n ot per ect m arkers o
n u trition al statu s, bu t sh ou ld be evalu ated or an y
patien t w ith a n on h ealin g w ou n d
Wou n d cu ltu res sh ou ld on ly be obtain ed i cellu litis is
su spected to h elp gu ide an tibiotic th erapy. I a cu ltu re is
in dicated, th e sam ple sh ou ld be obtain ed a ter a w ou n d
h as been th orou gh ly clean sed an d debrided [25, 26]
2 .2 Diffe re n t ia t io n o f ch ro n ic u lce rs
Ch aracteristic clin ical location an d appearan ce u su ally
allow s or clear distin ction betw een isch em ic, ven ou s, an d
n eu ropath ic u lcers ( Ta b le 14 -2 ).

266 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jorge Danie l Barla, Luciano Rossi, Yoav Rosenthal, Ste ve n Ve lke s
Ischemic ulcers
Pathophysiology: inadequate perfusion due to arterial obstruction
Obstruction may be caused by atherosclerosis affecting the large or medium arteries,
or from other disorders that affect the small vessels (eg, thromboangiitis obliterans or
Buergers disease, vasculitis, scleroderma)
Pain in the extremity at rest, and increased pain with elevation of the extremity and
activity. Pain may be localized to the ulcer or more generalized to the foot
Location over prominent osseous areas and other areas where there is a potential
for pressure and skin shearing including between the toes, on the tips of toes, over
phalangeal tufts, at the lateral malleolus
Venous ulcers
Most common type
Predisposing factors: deep vein thrombosis and venous valvular incompetence. Medial
and lateral malleoli are the most common sites
Periwound skin: is often eczematous, presenting with erythema, scaling, weeping, and
crusting
Intense pruritus in the region
Hyperpigmentation and stasis dermatitis of the surrounding skin. Frequently red with
granulation tissue
Calcification in wound base is common
Pressure ulcers
Pressure ulcers are areas of necrosis and ulceration where soft-tissue structures are
compressed between osseous prominences or hard external surfaces
Ulcer severity ranges from nonblanchable skin erythema (stage I) to full-thickness skin
loss with extensive soft-tissue necrosis (stage III) and full-thickness skin/muscle necrosis
with exposed structures, such as muscle, tendon, and bone (stage IV). The diagnosis
is clinical
Location over osseous prominences including the medial and lateral metatarsal heads,
calcaneus, ischial tuberosities, greater trochanter, fibular head, and sacrum
Fibrotic tissue including necrotic eschar
Deep probing to the level of bone and undermining of skin edges
Surrounding periwound erythema
Diabetic neuropathic ulcers
Multifactorial: diabetic neuropathy, autonomic dysfunction, and vascular insufficiency
Characteristics of neuropathic diabetic ulcers include:
Location at areas of repeated trauma, such as the plantar metatarsal heads or dorsal
interphalangeal joints
Overgrowth of hyperkeratotic tissue (corns or calluses) on other regions of the foot.
Hyperkeratotic callous formation may imply adequate vascularity
Undermined borders
Lack of sensation
Malignant ulcers
Tumors can present with features similar to chronic wounds, and may not be easily
distinguished from a venous ulcer
Skin biopsy should be considered in any nonischemic wound that does not
demonstrate signs of healing after approximately 3 months of treatment [28 ]
Hypertensive ulcers
Uncommon and can be easily confused with other types of chronic ulcers
Pathophysiology: calcification that obliterates small arterioles similar to calcific uremic
arteriolopathy [29 ]
The typical hypertensive ulcer is located in the supramalleolar region of the
anterolateral leg or Achilles tendon. Bilateral ulcers are common. These are associated
with arterial hypertension in patients with perceptible pulses
The reduction in tissue perfusion leads to local ischemia and ulcer formation. The ulcer
begins as a red patch which becomes cyanotic, forming a painful ulcer with an ischemic
wound bed
Management consists of controlling hypertension and local wound care
Ta b le 14 -2 Chronic ulce rs.
3 Wo u n d m a n a ge m e n t
3 .1 In it ia l m a n a ge m e n t
Irrigation an d debridem en tw ou n ds th at h ave devitalized
tissu e, con tam in ation , or residu al su tu re m aterial requ ire
debridem en t be ore u rth er w ou n d m an agem en t. Th ese
m aterials im pede th e bodys attem pt to h eal by stim u latin g
th e produ ction o abn orm al m etalloproteases an d con su m -
in g th e local resou rces n ecessary or h ealin g [30 ].
Irrigation h elps to decrease th e bacterial load an d rem ove
loose m aterial, an d sh ou ld be a part o rou tin e w ou n d
m an agem en t [31 ]. Warm , isoton ic (n orm al) salin e is typi-
cally u sed at low pressu re. Th e addition o dilu te iodin e or
oth er an tiseptic solu tion s (eg, ch lorh exidin e an d h ydrogen
peroxide) is gen erally u n n ecessary. Th ese solu tion s h ave
m in im al e ect again st bacteria an d cou ld poten tially im pede
w ou n d h ealin g th rou gh toxic e ects on n orm al tissu e (see
ch apter 6 Local delivery o an tibiotics an d an tiseptics or
addition al in orm ation ) [3 2 ]. Low pressu re irrigation is
u su ally adequ ate to rem ove m aterial rom th e su r ace o
m ost w ou n ds. Rem ovin g large areas o n ecrotic tissu e is
in dicated w h en ever th ere is an y eviden ce o in ection (ie,
cellu litis, sepsis). Su rgical debridem en t is also in dicated in
th e m an agem en t o ch ron ic n on h ealin g w ou n ds to rem ove
in ectiou s debris, h an dle u n derm in ed w ou n d edges, or
obtain deep tissu e or cu ltu re an d path ology [3 3 ]. Serial
su rgical debridem en t in a clin ical settin g, w h en appropriate,
appears to be associated w ith an in creased likelih ood o
h ealin g [34].
3 .2 To p ica l t h e ra p y
Grow th actorsu se o grow th actors im portan t or w ou n d
h ealin g in clu des platelet-derived grow th actor (PDGF),
ibroblast growth actor, an d gran u locyte-m acroph age colon y
stim u latin g actor (GM-CSF):
Platelet-derived grow th actor: platelet-derived grow th
actor is a gel preparation th at prom otes cellu lar
proli eration an d an giogen esis, an d th ereby im proves
w ou n d h ealin g [35 ]. It is in dicated or n on in ected
diabetic oot u lcers th at exten d in to th e su bcu tan eou s
tissu e an d h ave an adequ ate vascu lar su pply [35].
Epiderm al grow th actor: topical application o h u m an
recom bin an t epiderm al grow th actor w as associated
w ith a greater redu ction in u lcer size an d h igh er
u lcerh ealin g rate com pared w ith placebo [36].
Gran u locyte-m acroph age colon y stim u latin g actor
in traderm al in jection s o GM-CSF prom ote h ealin g o
ch ron ic leg u lcers, in clu din g ven ou s u lcers [37].
267
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14
O pe n
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3 .3 Wo u n d d re s s in gs Acu te w ou n d f u id is rich in platelet-derived grow th actor,

Th e dressin g can h ave a sign i can t im pact on th e speed o basic broblast grow th actor, an d h as a balan ce o m etal-
w ou n d h ealin g [38]. loproteases servin g a m atrix cu stodial u n ction [4 0 ]. In
addition to aster w ou n d h ealin g, w ou n ds treated w ith
Som e gen eral prin ciples or ch ron ic w ou n d m an agem en t occlu sive dressin gs are associated w ith less prom in en t scar
are [39 ]: orm ation [41].

Hydrogels or th e debridem en t stage Dressin gs can be classi ed by th eir w ater-retain in g abilities

Foam an d low -adh eren ce dressin gs or th e gran u lation as open , sem iopen , or sem iocclu sive ( Ta b le 14-3 ).
stage
Hydrocolloid an d low -adh eren ce dressin gs or th e
epith elialization stage
Hu m an stu dies sh ow ed th at m oist w ou n ds h eal m ore
rapidly com pared w ith dry w ou n ds [38]

Open dressings Alginates Natural complex polysaccharides from various types of algae form
Gauze is typically moistened with saline before placing it into the wound. the basis of alginate dressings. Their activity as dressings is unique
Wet-to-moist gauze dressings are useful for packing large soft-tissue defects until wound because they are insoluble in water but in the sodium-rich wound fluid
closure or coverage can be performed. environment these complexes exchange calcium ions for sodium ions
Advantage: and form an amorphous gel that packs and covers the wound [44 ].
Inexpensive More appropriate for moderately to heavily exudative wounds.
Disadvantage: Advantages:
Require frequent dressing changes Augmentation of hemostasis
Can be washed away with normal saline to minimize pain during
Semiopen dressings
dressing changes
Typically consist of fine mesh gauze impregnated with petroleum, paraffin wax, or other
Can stay in place for several days
ointment. This initial layer is covered by a secondary dressing of absorbent gauze and
Disadvantages:
padding, then finally a third layer of tape or other method of adhesive.
Require secondary dressing that must be removed to monitor the
Advantage:
wound
Low cost and ease of application
Unpleasant odor
Disadvantages:
Does not maintain a moisture-rich environment or provide good exudate control Hydrocolloids Agel or foam on a carrier of self-adhesive polyurethane film. The
Need for frequent changing colloid composition of this dressing traps exudate and creates a
moist environment. Bacteria and debris are also trapped, and washed
Semiocclusive dressings
away with dressing changes in a gentle, painless form of mechanical
Semiocclusive dressings include films, foams, alginates, hydrocolloids, and hydrogels.
debridement.
Films Polymer films are transparent sheets of synthetic self-adhesive dressing Advantage:
that are permeable to gases, such as water vapor and oxygen, but Ability to use them for packing wound
impermeable to larger molecules including proteins and bacteria. Disadvantages:
This property enables insensible water loss to evaporate, traps wound Malodor
fluid enzymes within the dressing, and prevents bacterial invasion. Potential need for daily dressing changes, and allergic contact
Transparent film dressings were found to provide the fastest healing dermatitis has been reported [4 5]
rates, lowest infection rates, and to be the most cost-effective method
Hydrogels Amatrix of synthetic polymers with > 95% water formed into sheets,
for dressing split-thickness skin graft donor site [42 ].
gels, or foams that are usually sandwiched between two sheets of
Advantages:
removable film. The inner layer is placed against the wound, and the
Ability to maintain moisture
outer layer can be removed to make the dressing permeable to fluid.
Encourage rapid reepithelization
These unique matrices can absorb or donate water depending on the
Transparency and self-adhesive properties
hydration state of the tissue that surrounds them.
Disadvantage:
Hydrogels are most useful for dry wounds.
Limited absorptive capacity
Advantage:
Foams They consist of two layers: a hydrophilic silicone or polyurethane-based They initially lower the temperature of the wound environment they
foam, which lies against the wound surface, and a hydrophobic, gas- cover, which provides cooling pain relief for some patients [4 6]
permeable backing to prevent leakage and bacterial contamination [43]. Disadvantage:
Advantages: They have been found to selectively permit gram-negative bacteria
Highly absorbent to proliferate [47]
Conform to the shape of the wound and can be used to pack
Hydroactive Polyurethane matrix that combines the properties of a gel and foam.
cavities.
Hydroactive selectively absorbs excess water while leaving growth
Disadvantages:
factors and other proteins behind [4 8].
Opacity of the dressings
Need to be changed each day

Ta b le 14 -3 Wound dre ssings.

268 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jorge Danie l Barla, Luciano Rossi, Yoav Rosenthal, Ste ve n Ve lke s
4 Wo u n d co ve ra ge
4 .1 Sk in gra ft s
Skin gra ts are th e m ost basic biological dressin gs an d con -
sist o skin taken rom a don or site an d gra ted on to a w ou n d
on th e sam e patien t. Skin gra ts are u sed or w ou n d closu re,
to preven t f u id an d electrolyte loss, an d redu ce bacterial
bu rden an d in ection [49, 50].
4 .2 Fu ll-t h ick n e s s s k in gra ft s
Fu ll-th ickn ess skin gra ts con tain th e epiderm is an d derm is,
an d th u s retain m ore o th e ch aracteristics o n orm al skin ,
in clu din g color, textu re, an d th ickn ess com pared w ith split-
th ickn ess skin gra ts. Fu ll-th ickn ess skin gra ts are lim ited
to relatively sm all, u n con tam in ated, w ell-vascu larized
w ou n ds. Th e skin u sed or u ll-th ickn ess skin gra ts is ob-
tain ed rom areas o redu n dan t an d pliable skin , su ch as th e
groin , lateral th igh , low er abdom en , or lateral ch est. Don or
sites are u su ally closed prim arily. Th e m ain disadvan tages
o u ll-th ickn ess skin gra ts in clu de lim ited availability o
don or skin an d th e poten tial or f u id accu m u lation ben eath
th e gra t [49, 50].
a b
c d
Fig 14 -1 a e An e xam ple of a posttraum atic skin de fe ct m anage d with a split-thickne ss skin graft.
a Pre ope rative image .
b Intraope rative image shows split-thickne ss skin graft.
ce Postope rative im age s show a he ale d split-thickne ss skin graft on the dorsum of the foot and ante rior ankle . The patie nt has re gaine d
e xce lle nt range of dorsi e xion and plantar e xion with this cove rage te chnique .
4 .3 Sp lit-t h ick n e s s s k in gra ft s
Split-th ickn ess skin gra ts are com m on ly u sed tissu e or
w ou n d coverage.
Com pared w ith u ll-th ickn ess skin gra ts, split-th ickn ess
skin gra ts tolerate a less th an ideal w ou n d bed an d h ave a
broader ran ge o application s. Split-th ickn ess skin gra ts can
be m esh ed to provide coverage o a greater su r ace area at
th e recipien t site, w ith expan sion ratios gen erally ran gin g
rom 1:1 to 6:1. Split-th ickn ess skin gra t don or sites h eal
spon tan eou sly with cells su pplied by th e rem ain in g epiderm al
appen dages. Don or sites can be reh arvested on ce h ealin g is
com plete.
Split-th ickn ess gra ts h ave disadvan tages. Th ey are m ore
ragile, especially w h en placed over areas w ith little u n der-
lyin g so t-tissu e bu lk or su pport. Split-th ickn ess gra ts
con tract m ore du rin g h ealin g, do n ot grow w ith th e in di-
vidu al, an d ten d to be sm ooth er an d sh in ier th an n orm al
skin becau se o th e absen ce o skin appen dages in th e gra t.
Th ey also ten d to be abn orm ally pigm en ted, eith er pale or
w h ite, or altern atively, h yperpigm en ted, particu larly in
darker-skin n ed in dividu als. For th ese reason s, split-th ickn ess
skin gra ts are m ore w idely u sed or con trol o in ection an d
preven tion o f u id/ electrolyte loss rath er th an cosm esis [51].
Fig 14 -1 is an exam ple o a posttrau m atic skin de ect m an aged
w ith a split-th ickn ess skin gra t.
e
269
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4 .4 Bio lo gica l (ce ll-b a s e d d re s s in gs)
Biological (cell-based dressin gs) are com posed o a live-cell
con stru ct th at con tain s at least on e layer o live allogen ic
cells.
Cell-based dressin gs can be u sed w h en tradition al dressin gs
h ave ailed or are deem ed in appropriate [5 2 ]. Cell-based
dressin gs are ideal or th e treatm en t o ch ron ic u lcers becau se
addition al cells an d grow th actors are added to a de cien t
w ou n d-h ealin g en viron m en t. Accelerated w ou n d h ealin g
redu ces th e risk o w ou n d in ection .
270
5 Ad ju n ct ive t h e ra p ie s
5 .1 Hyp e rb a ric o xyge n t h e ra p y (HBOT)
Th is h as been sh ow n in vitro to h ave e ects on w ou n d
h ealin g [53, 54]. En doth elial progen itor cells play an im por-
tan t role in w ou n d h ealin g becau se th ey participate in th e
orm ation o n ew blood vessels in areas o h ypoxia [53, 54].
Hyperbaric oxygen th erapy m ay im prove th e su rvival o
skin gra ts an d recon stru ctive f aps th at h ave com prom ised
blood f ow , th ereby preven tin g tissu e breakdow n an d th e
developm en t o w ou n ds.
5 .2 Fla p s
High -en ergy trau m a can be associated with severe so t-tissu e
in ju ry. Wide areas o n ecrosis requ ire aggressive debride-
m en t an d lead to large de ects th at can requ ire f ap coverage.
Besides u sin g n egative-pressu re w ou n d th erapy (NPWT) as
a tem porary device, all th e above-described available m eth -
ods m ay n ot be su itable in th is scen ario. It is kn ow n th at
com plete w ou n d coverage be ore 1 w eek im proves resu lts,
th u s redu cin g com plication s like in ection an d bon e h ealin g
[55, 56].
Depen din g on th e type, size, an d w ou n d location , a local
pedicu lated or a distan t m icrovascu larized f ap m ay be u sed.
Wou n ds associated w ith a ractu re at th e sam e level u su -
ally requ ire a m u scle f ap ollow ed by a split-th ickn ess skin
gra t, skin plu s su bcu tan eou s tissu e, or som e com bin ation
o th em [5 7 5 9 ]. A vascu lar evalu ation m u st to be don e
prior to an y f ap. An giograph y, com pu ted tom ograph ic
an giograph y, an d/ or Doppler u ltrasou n d can be u sed.
Fig 14 -2sh ow s a large plan tar de ect secon dary to an open
calcan eal ractu re treated w ith a su ral f ap. In Fig 14 -3 an
open type IIIB tibial ractu re m an aged u sin g an an terolat-
eral th igh f ap is presen ted.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Jorge Danie l Barla, Luciano Rossi, Yoav Rosenthal, Ste ve n Ve lke s

a b

Fig 14-2a e A large plantar de fe ct se condary to

an ope n calcane al fracture tre ate d with a sural ap.
a b Pre ope rative image s.
c Intraope rative image be fore sural ap
cove rage .
d Intraope rative image afte r sural ap cove rage .
c d e e Postope rative he aling.

b c d
Fig 14 -3a d Ope n type IIIB tibial fracture manage d using an ante rolate ral thigh ap.
a Pre ope rative image with e xte rnal xator.
b Intraope rative image showing marke d out ante rolate ral thigh ap.
c Intraope rative image showing place m e nt of ante rolate ral thigh ap.
d Postope rative he aling.

271
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6 Ne ga t ive -p re s s u re w o u n d t h e ra p y fo r t h e in creasin g popu larity [6 1 ]. Th is in n ovative m eth od h as

t re a t m e n t o f o p e n w o u n d s
6 .1 In t ro d u ct io n
Du e to h igh rates o m ilitary an d civilian trau m a, ph ysician s
are o ten aced w ith ch allen gin g h igh -en ergy so t-tissu e
w ou n ds an d ractu res, dem an din g com plex su rgical proce-
du res. Th e agin g popu lation an d th e in creasin g prevalen ce
o obesity an d diabetes m ellitu s con tribu te to th e rise in th e
in ciden ce o ch ron ic w ou n ds th at are becom in g an in creas-
in g bu rden to ou r h ealth care system . Better, cost-e ective
m eth ods o closin g di cu lt w ou n ds e cien tly w ill redu ce
th e pain an d am pu tation rates associated w ith th ese w ou n ds
[60].
Negative-pressu re w ou n d th erapy h as been u sed sin ce 1940,
bu t w ith th e in trodu ction o vacu u m -assisted closu re (VAC),
a orm o topical n egative pressu re, in 1996, it h as gain ed
im proved an d revolu tion ized w ou n d care treatm en t. Th e
tech n iqu e in volves an open cell- oam dressin g pu t in to th e
w ou n d cavity, con n ectin g it to a vacu u m pu m p w ith a tu be
an d coverin g it w ith an adh esive drape. A con trolled con -
tin u ou s or in term itten t su batm osph eric pressu re o 125 m m
Hg is applied [62]. An illu strative case in Fig 14-4 dem on strates
th e e cacy o NPWT to acilitate w ou n d h ealin g o an in ec-
tion a ter rem oval o in ected h ardw are.
Low er extrem ity w ou n ds w ith exposed ten don , bon e, or
xation device presen t a di cu lt treatm en t ch allen ge. De-
Fran zo et al [63] sh ow ed greatly redu ced tissu e edem a, di-
m in ish ed circu m eren ce o th e extrem ity, an d th u s decreased
w ou n ds su r ace area by u sin g NPWT. Th is m eth od led to a
pro u se gran u lation tissu e respon se th at rapidly covered
bon e an d h ardw are, allow in g su ccess u l prim ary closu re,
w ith ou t com plication s in rou gh ly 95% o patien ts [63 ].

a b c

d e f
Fig 14 -4 a f Clinical e xam ple: tre atm e nt of a surgical wound infe ction with a dif cult wound closure . A 5 8 -ye ar-old man with diabe te s was
adm itte d with a close d distal m e taphyse al fracture of the tibia. He unde rwe nt ope n re duction and inte rnal xation with a plate .
a b Six m onths late r he de ve lope d a wound infe ction ( a ) that was tre ate d with surgical incision, drainage and im plant re m oval ( b ). His
wound was tre ate d with thre e cycle s of ne gative -pre ssure wound the rapy (NPWT) dre ssings.
c He the n unde rwe nt approxim ation of the e dge s of the wound using nylon suture s.
d Following closure , he had thre e additional cycle s of NPWT.
e f This was followe d by local dre ssing till se condary closure that was achie ve d within a fe w we e ks.

272 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jorge Danie l Barla, Luciano Rossi, Yoav Rosenthal, Ste ve n Ve lke s
6 .2 Me ch a n is m o f a ct io n
Negative-pressu re w ou n d th erapy acilitates w ou n d h ealin g
th rou gh m u ltiple m ech an ism s o action both at th e m acro-
scopic an d m icroscopic levels. Th ere are ou r prim ary m ech -
an ism s o action o th e NPWT device described in th e
literatu re:
Con traction o th e w ou n d (m acrode orm ation ):
m ain tain in g approxim ation o tissu es du rin g w ou n d
h ealin g allow s earlier closu re by delayed prim ary or
secon dary gran u lation . Th e open -pore polyu reth an e
oam th at is u sed w ith th e NPWT device e cien tly
tran sm its pressu re an d evacu ates exu dates. For
de orm able w ou n ds, cu ttin g th e oam in a strategic
ash ion w ill acilitate w ou n d closu re by allowin g th e
wou n d edges to com e togeth er m ore qu ickly [60, 64].
Stabilization o th e w ou n d en viron m en t: NPWT
provides an isolated, w arm , an d m oist en viron m en t.
Th e NPWT device u ses a sem iocclu sive polyu reth an e
drape th at h as lim ited perm eability to gases an d w ater
vapor an d im perm eability to protein s an d m icroorgan -
ism s. Th e dressin g is typically ch an ged every 23 days,
w h ich elim in ates th e discom ort o th e daily dressin g
ch an ges typically associated with tradition al gau ze-based
dressin gs [60 , 6 4 ].
Rem oval o extracellu lar f u id: edem a im pedes h ealin g
an d th u s elevation an d com pression o extrem ities to
decrease edem a an d acilitate h ealin g is recom m en ded.
Application o a distribu ted su ction allow s evacu ation
o f u id directly rom th e extracellu lar space an d
appears to decrease edem a. Fu rth erm ore, it assists by
rem ovin g in f am m atory m ediators an d cytokin es [60, 64].
Microde orm ation at th e oam -w ou n d in ter ace:
com pu ter m odels h ave sh ow n th at NPWT produ ces
520% strain across th e h ealin g tissu es. In vivo m odels
sh ow ed stim u lation o w ou n d h ealin g th rou gh prom o-
tion o cell division an d proli eration , grow th actor
produ ction , an d an giogen esis [65].
Wan g et al [66] sh ow ed th at NPWT sign i can tly in creased
th e expression o ICAM-1, MIF, VEGF an d collagen I an d
th ere ore, in dicate th at NPWT th erapy is an e ective m eth -
od or treatin g severe trau m atic w ou n ds, as it in creases th e
expression o cytokin es in w ou n ds. Fu rth erm ore, stu dies
h ave sh ow n th at a con trolled su batm osph eric pressu re o
125 m m Hg to porcin e w ou n ds in creased blood f ow in th e
area ou r old an d bacteria levels decreased sign i can tly in
ou r days [67].
Th ere are six secon dary e ects:
Speed o w ou n d h ealin g: Egin ton et al [68] w itn essed a
sign i can t redu ction o w ou n d volu m e by u sin g NPWT
in com parison w ith n orm al salin e dressin gs. Fu rth er-
m ore, m icroscopic an alysis o w ou n d cross-section s
sh ow ed a sign i can t in crease in th e gran u lation tissu e
am ou n t per w ou n d u n it len gth in NPWT-treated
com pared w ith occlu sive dressin gs [6971]. How ever,
th e Coch ran e review [68] ou n d n o eviden ce to su pport
th e e ectiven ess o NPWT to redu ce tim e to com plete
h ealin g.
Gran u lation tissu e orm ation : th e application o NPWT
resu lts in an im pressive gran u lation tissu e respon se.
Th is m ay be con tribu ted to by m icrode orm ation , w h ich
in du ces localized h ypoxia n ear th e w ou n d su r ace th at
u pregu lates th e HIF-1 -VEGF path w ay [60, 72].
Cell proli eration : at least th ree o th e prim ary m ech a-
n ism s are likely to con tribu te to proli eration , in clu d-
in g m icrode orm ation , f u id rem oval, an d m ain ten an ce
o a w arm an d m oist w ou n d en viron m en t [60, 72].
Modu lation o in f am m ation : m ast cells, or exam ple,
play an im portan t role in w ou n d h ealin g, as in m ast
cell-de cien t m ice, gran u lation tissu e respon se h as
been sh ow n to be m u ted, su ggestin g th at m ast cells are
critical or NPWT su ccess [73].
Ch an ge in n eu ropeptides: NPWT resu lted in a sign i -
can t in crease in derm al an d epiderm al n erve ber
den sities an d in su bstan ce P, calciton in gen e-related
peptide, an d n erve grow th actor expression w as seen
in NPWT-treated w ou n ds, su ggestin g th at NPWT can
m odu late n erve ber an d n eu ropeptide produ ction in
th e w ou n d [69].
Ch an ge in bacterial levels: redu cin g th e bacterial loads
o a w ou n d im proves its h ealin g capacity becau se th e
body can th en con cen trate on h ealin g rath er th an
gh tin g an in vasion by bacteria, viru s, or yeast.
Variou s stu dies h ave sh ow n both in creased an d
decreased bacterial levels ollow in g th e u se o NPWT.
For in stan ce, Mou es et al [70] com pared NPWT to m oist
gau ze dressin gs in 54 patien ts an d ou n d stable
bacterial load in both grou ps. However, n on erm en tative
gram -n egative bacilli sh ow ed a sign i can t decrease in
NPWT-treated w ou n ds, w h ereas Staphylococcus aureus
sh ow ed a sign i can t in crease in NPWT-treated
w ou n ds.
273
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6 .3 In d ica t io n s a n d co n t ra in d ica t io n s Stan n ard et al [7 7 ] ran tw o parallel stu dies regardin g th e

Meetin g th e correct in dication s an d avoidin g th e con train -
dication s is cru cial or u sage o NPWT. Be ore th e application
o NPWT, th e patien t an d w ou n d m u st be assessed or th e
appropriaten ess o th e treatm en t. In 1995 th e US Federal
Dru g Adm in istration (FDA) approved VAC or NPWT or
th e treatm en t o n on h ealin g w ou n ds an d expan ded th e
in dication s in 2000 to in clu de ch ron ic, acu te, trau m atic an d
su bacu te w ou n ds, f aps, an d gra ts ( Ta b le 14 -4 ) [74].
6 .4 Ut iliza t io n o f NP WT in t h e s e t t in g o f a cu t e
o r t h o p e d ic t ra u m a
Regardless o th e u se o NPWT, th e prim ary su rgical treat-
m en t o an open ractu re m u st alw ays begin w ith th orou gh
debridem en t an d stabilization o th e ractu re be ore address-
in g th e so t-tissu e de ects [75].
Parrett et al [76] exam in ed th e tren ds in th e m an agem en t
o so t-tissu e in ju ries in open tibial ractu res. Th ey dem on -
strated a ch an ge in practice w ith a tren d dow n th e recon -
stru ctive ladder. In 1997, th e au th ors began u sin g NPWT
an d n ow u se it in n early h al o all open ractu res. On th e
oth er h an d, th ey u se ew er ree f aps. Despite th is tren d,
th ere h as been n o ch an ge in in ection , am pu tation , or m al-
u n ion / n on u n ion rates an d a decrease in reoperation rate
w ith at least 1-year ollow -u p [76 ].
DeFran zo et al [63] reported 100% closu re rates o ch allen gin g
w ou n ds (eg, over exposed bon es, ten don s, or im plan ts) w ith
u se o NPWT.
Indications
Chronic wounds
Acute wounds
Traumatic wounds (soft-tissue injuries)
Infected wounds (necrotizing fasciitis)
Subacute wounds
Dehisced wounds
Partial-thickness burns
Ulcers and pressure sores
Flaps and grafts
Contraindications
Wounds with necrotic tissue
Untreated osteomyelitis
Fistulas to organs or body cavities
Placement directly over exposed veins, arteries, or nerves
Malignancy within the wound
Sensitivity to silver (in the case of silver impregnated dressings only)
e cacy o NPWT. Th e rst stu dy w as an evalu ation o th e
u se o NPWT to assist in evacu ation o a drain in g h em atom a
an d in closu re o th e su rgical in cision . Th e grou p ou n d th at
NPWT redu ced th e h em atom a drain in g tim e an d in ection
rate by n early h al ( rom 3.1 to 1.6 days). Th e secon d stu dy
w as an evalu ation o NPWT as an adju n ct to h ealin g o
su rgical in cision s a ter ractu res th at are at h igh risk or
w ou n d-h ealin g problem s (ie, patien ts w ith on e o th ree
h igh -risk ractu res a ter h igh -en ergy trau m acalcan eu s,
pilon , an d Sch atzker IV th rou gh VI tibial plateau ractu res).
Again , drain in g tim e w as sign i can tly redu ced bu t n ot th e
in ection rate.
In a di eren t stu dy [78], th e sam e au th ors in vestigated 263
trau m a patien ts w ith on e o th ree h igh -risk ractu re types
(tibial plateau , pilon , calcan eal) requ irin g su rgical stabiliza-
tion an d sh ow ed a decreased in ciden ce o w ou n d deh iscen ce
an d total in ection s a ter h igh -risk ractu res w h en patien ts
h ave NPWT applied to th eir su rgical in cision s a ter closu re
in com parison w ith stan dard postoperative dressin gs.
Labler an d Tren tz [79] exam in ed 13 patien ts with trau m atic
pelvic in ju ries an d con clu ded th at th e application o NPWT
as tem porary coverage o large-tissu e de ects in pelvic region s
su pports w ou n d con dition in g an d acilitates th e de n itive
w ou n d closu re.
An oth er stu dy w as con du cted in th e Him alayan In stitu te o
Medical Scien ces by Sin h a et al [80 ], in volvin g 30 patien ts
w ith open m u scu loskeletal in ju ries in extrem ities requ irin g
coverage procedu res. Th e au th ors com pared NPWT w ith
stan dard salin e dressin gs an d ou n d th e ollow in g:
Th ere w as sign i can t decrease in w ou n d size rom day
0 to day 8 in th e NPWT grou p com pared w ith th e
salin e grou p.
Th ere w as sign i can t decrease in th e bacterial grow th
in th e NPWT grou p com pared w ith th e salin e grou p.
How ever, Dedm on d et al [81 ] exam in ed 50 grade III open
tibial sh a t ractu res, w h ich did n ot sh ow NPWT su perior-
ity in redu cin g in ection an d n on u n ion rates com pared w ith
h istorical con trols, bu t con clu ded th at th is tech n iqu e m ay
be ben e cial in decreasin g th e n eed or ree tissu e tran s er
or rotation al m u scle f ap coverage.

Ta b le 14 -4 Indications and contraindications for the use of

ne gative -pre ssure wound the rapy.

274 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jorge Danie l Barla, Luciano Rossi, Yoav Rosenthal, Ste ve n Ve lke s
Negative-pressu re w ou n d th erapy is bein g w idely u sed an d
is su pported or u se or a ran ge o su rgical application s.
How ever, th ere is n o eviden ce to su pport or re u te th e
e ectiven ess o NPWT to im prove h ealin g rates or to redu ce
tim e to com plete h ealin g rom a large-scaled Coch ran e
review , exam in in g ve stu dies, ollow in g 280 patien ts [82].
In th e case o pediatric patien ts, Halvorson et al [83] com pared
th e u se o NPWT w ith h istorical con trols, an d con clu ded
th at th e u se o NPWT th erapy or pediatric open ractu res
in variou s location s appears to be an equ ally sa e an d e ec-
tive m odality to h elp redu ce in ection in pediatric open
ractu res.
6 .5 Tip s a n d p re ca u t io n s
Preven tive m easu res in clu de [72 ]:
Negative-pressu re w ou n d th erapy is n ot a su bstitu te
or adequ ate debridem en t or recon stru ctive tech n iqu es,
su ch as a skin gra t or f ap.
Placin g on ly on e piece o oam in to a sin gle w ou n d,
w h en possible, is h igh ly recom m en ded. I m ore th an
on e piece o oam is placed, ph ysician s an d n u rses
sh ou ld care u lly docu m en t th e n u m ber o oam pieces
placed to redu ce th e ch an ce o a orgotten piece.
Du e to som e case reports o bleedin g w h ile u sin g
NPWT, w h en placin g NPWT over blood vessels or
organ s, a n on adh eren t dressin g or a th ick layer o tissu e
sh ou ld cover th e vessels or organ to redu ce th e risk o
bleedin g. Fu rth erm ore, care m u st be taken w h en u sin g
NPWT im m ediately a ter a large debridem en t or w h en a
patien t is receivin g an ticoagu lation th erapy.
Wh en th e clin ician an ticipates w ou n d adh esion to th e
dressin g, a w ou n d con tact layer can be placed u n der
th e w ou n d. Th e u se o a n on adh eren t w ou n d con tact
layer preven ts th e grow th o tissu e in to oam , th u s
acilitatin g dressin g ch an ges, alth ou gh th is m ay sligh tly
redu ce th e orm ation o gran u lation tissu e.
An oth er strategy to redu ce th e degree o w ou n d-bed
adh esion is by in creasin g th e requ en cy o dressin g
ch an ges, th u s redu cin g th e pain du rin g dressin g
ch an ges. An oth er requ en tly u sed m eth od is to in still
salin e in to th e w ou n d th rou gh th e w ou n d ller 1530
m in u tes be ore gen tly rem ovin g th e dressin g [84 ].
6 .6 Eva lu a t io n o f t re a t m e n t
Regu lar review progress is essen tial, especially w ith an
accu rate an d reprodu cible m eth od o w ou n d m easu rem en t.
As lon g as th ere is a su bstan tial redu ction in w ou n d area
a ter 1 or 2 w eeks, con tin u ation o NPWT is stron gly in di-
cated w ith requ en t reassessm en ts. How ever, i im provem en t
h as ceased, NPWT ou gh t to be discon tin u ed.
In ch ron ic w ou n ds, an e ective gen eral assessm en t m easu re
is to assess th e:
Wou n d m argin s or in f am m ation a ter th e rst
application o NPWT th erapy. In creased in f am m ation
m ay be an in dication or treatm en t discon tin u ation .
Wou n d m argin s or a th in w h ite epith eliu m a ter th e
secon d an d su bsequ en t application s, w h ich in dicates
h ealin g.
Overall appearan ce o th e w ou n d bed. A bee y,
gran u lar appearan ce is a positive ou tcom e, w h ile a
du sky bed in dicates in adequ ate tissu e per u sion .
Gran u lation tissu e sh ou ld in crease by arou n d 35%
per day.
6 .7 Co m p lica t io n s o f NP WT
Alth ou gh th e in trodu ction o NPWT w as a breakth rou gh in
w ou n d m an agem en t an d h as sign i can tly im proved w ou n d
h ealin g, n o m eth od is per ect, an d NPWT is n o exception ;
com plication s are in requ en t bu t can be seriou s. Th ese in -
clu de pain , trau m a, or skin dam age, bleedin g, in ection ,
an xiety, im paired qu ality o li e, an d m aln u trition [85].
6 .7.1 Pa in
In addition to th e e ects on a patien ts w ell-bein g, h igh
levels o pain h ave also been lin ked to delayed h ealin g an d
th ere ore prolon ged treatm en t [86 ]. Patien ts treated w ith
NPWT en cou n ter pain , particu larly du rin g start-u p su ction
an d dressin g rem oval [87]. Webster et al [82] reported th at
pain levels w ere low er in patien ts w h o received h ospital-
based NPWT in com parison to patien ts w h o h ad com m ercial
NPWT closu re.
6 .7.2 Tra u m a o r skin d a m a ge
Th is m ay occu r w h en tissu e grow s in to th e oam on th e
dressin g. On e trial [84] h as en cou n tered a h igh in ciden ce o
ractu re blisters in th e NPWT grou p (62.5% ) com pared w ith
th e stan dard dressin g grou p (8.3% ).
Bleedin g h as been reported in som e stu dies o NPWT, bu t
th e n u m ber o cases is sm all [86].
6 .7.3 In fe ctio n
Clin ically, NPWT pow ered by con tin u ou s electricity-rem oved
exu date kept th e w ou n d clean an d acilitated w ou n d h eal-
in g. Wh en pow er w as o , spon ges coverin g th e w ou n d w ere
oreign an d acted as th e sou rce o in ection . I th e spon ges
ell ou t o place, th e wou n d bed was open to th e en viron m en t
an d th e risk o in ection in creased. Th is does n ot seem to
be th e case in cen tral n egative pressu re [85].
275
 Se ct io n 2Spe cial
situations
14
O pe n
wounds

6 .7.4 An xie t y 7 Co n clu s io n

It h as been ou n d th at th e stress associated w ith w ou n d
dressin g-ch an ge pain , or w ith th e an ticipation o pain , can
be related to delayed w ou n d h ealin g [88]. Patien ts receivin g
NWPT experien ced sign i can tly in creased an xiety scores in
com parison w ith th ose receivin g stan dard treatm en t [89].
6 .7.5 Qu a lit y o f life
Wh eth er NPWT im proves or h u rts a patien ts qu ality o li e
is con troversial an d stu dies vary betw een ben e t an d im -
pairm en t. Th e treatm en t pow ered by cen tral n egative pres-
su re or a portable m ach in e m ay lim it th e activities o patien ts.
Oth er decreases in qu ality o li e in clu ded poor appetite,
sleep problem s, an d even a ch an ge o cogn itive statu s [85 ].
Open w ou n ds represen t a sign i can t ch allen ge to th e m an -
agin g clin ician s. It is essen tial to per orm a th orou gh assess-
m en t o th e n atu re an d etiology o th e open w ou n d an d to
th orou gh ly com preh en d com orbidities th at m ay com plicate
its h ealin g. Th ere are m an y th erapies available to m an age
th e open w ou n d. A com preh en sive approach to th e problem
is n eeded. In som e cases, th e w ou n d can be m an aged w ith
local w ou n d care, w h ereas in oth er cases m ore aggressive
in terven tion s in clu din g h yperbaric oxygen th erapy, NPWT,
or su rgical treatm en t m ay be requ ired. In m an y cases,
requ en t assessm en ts an d a m u ltidisciplin ary approach to
th e problem w ill prove ben e cial to th e patien t.

6 .7.6 Ma ln u tritio n
Exu dates extracted rom patien ts w ith an open abdom en or
so t-tissu e w ou n ds treated w ith NPWT com prise a sign i can t
loss o protein , w h ich sh ou ld be con sidered w h en assessin g
protein requ irem en ts. Im m u n oglobu lin s an d electrolytes
losses w ere n oted as w ell [90].

6 .8 Co s t-e ffe ct ive n e s s

Th e cost-e ectiven ess w as in spected in a ew trials th at con -
clu ded th e ollow in g: u sage o NPWT resu lts in redu ction
in con su m ption o n u rsin g tim e; redu ction in pain scores
(a ter w eek 5 o treatm en t); redu ction in com plexity an d
n u m ber o su rgical procedu res/ adverse even ts; redu ction in
len gth o treatm en t an d h ospital stay/ n u m ber o h ospitaliza-
tion s; redu ction o total w ou n d care cost; im proved com ort
or th e patien t an d n u rses; an d im provem en t in clin ical
ou tcom e [61, 71, 91].

Th e daily cost o NPWT w as com pared w ith a n egative-

pressu re system developed in th e h ospital. Th e m ean cost
to su pply equ ipm en t or NPWT th erapy w as n early 25 tim es
m ore expen sive th an th e latter. For th ose w h o can n ot a ord
th e expen se o h irin g th e equ ipm en t requ ired or NPWT,
u sin g th e h ospitals aspiration system to ach ieve n egative
pressu re is probably as sa e as NPWT. Th ere are clear cost
ben e ts w h en n on com m ercial system s are u sed to create
th e n egative pressu re requ ired or w ou n d th erapy, w ith n o
redu ction in clin ical ou tcom e [82].

276 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

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proli eration an d rem odelin g ph ases o
m icrode orm ation al wou n d th erapy.
Plast Reconstr Surg. 2011
Dec;128(6):649e 658e.
74. Ka rla kk i S, Bre m M, Gia n n in i S, e t a l.
Negative pressu re wou n d th erapy or
m an agem en to th e su rgical in cision in
orth opaed ic su rger y: A review o
eviden ce an d m ech an ism s or an
em ergin g in dication . Bone Joint Res.
2013;2(12):276 28 4.
75. A N, Kh a n WS, J P. Th e eviden ce-based
prin ciples o n egative pressu re wou n d
th erapy in trau m a & orth opedics. Open
Orthop J. 2014;8:168 177.
76. Pa rre t t BM, Ma t ro s E, Prib a z JJ, e t a l.
Lower extrem ity trau m a: tren ds in th e
m an agem en t o so t-tissu e
recon stru ction o open tibia- bu la
ractu res. Plast Reconstr Surg. 2006
Apr;117(4):1315 1322; d iscu ssion
23 24.
77. St a n n a rd JP, Ro b in s o n JT, An d e rs o n ER,
e t a l. Negative pressu re wou n d th erapy
to treat h em atom as an d su rgical
in cision s ollow in g h igh -en ergy trau m a.
J Trauma. 2006 Ju n ;60(6):13011306.
78. St a n n a rd JP, Vo lga s DA, McGw in G, 3rd ,
e t a l. In cision al n egative pressu re
wou n d th erapy a ter h igh -risk lower
extrem ity ractu res. J Orthop Trauma.
2012 Jan ;26(1):3742.
Ste phe n L Kate s, Olivie r Bore ns
Jorge Danie l Barla, Luciano Rossi, Yoav Rosenthal, Ste ve n Ve lke s

79. La b le r L, Tre n t z O. Th e u se o vacu u m

assisted closu re (VAC) in so t tissu e
in ju ries a ter h igh en ergy pelvic
trau m a. Langenbeck s Arch Surg. 2007
Sep;392(5):601609.
80. Sin h a K, Ch a u h a n VD, Ma h e s h w a ri R,
e t a l. Vacu u m Assisted Closu re Th erapy
versu s Stan dard Wou n d Th erapy or
Open Mu scu loskeletal In ju ries.
Adv Orthop. 2013;2013:24594 0.
81. De d m o n d BT, Ko r t e s is B, Pu n ge r K,
e t a l. Th e u se o n egative-pressu re
wou nd th erapy (NPW T) in th e
tem porary treatm en t o so t-tissu e
in ju ries associated w ith h igh -en ergy
open tibial sh a t ractu res. J Orthop
Trauma. 2007 Jan ;21(1):1117.
82. We b s t e r J, Scu ffh a m P, Sh e rriff KL,
e t a l. Negative pressu re wou n d th erapy
or sk in gra ts an d su rgical wou n ds
h ealin g by prim ar y in ten tion . Cochrane
Database Syst Rev. 2012;4:CD009261.
83. Ha lvo rs o n J, Jin n a h R, Ku lp B, e t a l. Use
o vacu u m -assisted closu re in ped iatric
open ractu res w ith a ocu s on th e rate
o in ection . Orthopedics. 2011
Ju l;34(7):e256 260.
84. Ma lm s jo M, Gu s t a fs s o n L, Lin d s t e d t S,
e t a l. Negative pressu re wou n d
th erapy-associated tissu e trau m a an d
pain : a con trolled in vivo stu dy
com parin g oam an d gau ze dressin g
rem oval by im mu n oh istoch em istry or
su bstan ce P an d calciton in gen e-related
peptide in th e wou n d edge. Ostomy
Wound Manage. 2011 Dec;57(12):30 35.
85. Li Z, Yu A. Com plication s o n egative
pressu re wou n d th erapy: a m in i review.
Wound Repair Regen. 2014 Ju l-
Au g;22(4):4574 61.
86. Up t o n D, An d re w s A. Pain an d trau m a
in n egative pressu re wou n d th erapy: a
review. Int Wound J. 2013 Mar 12.
87. Vu o lo JC. Wou n d-related pain : key
sou rces an d triggers. Br J Nurs. 2009
Au g 13-Sep 9;18(15):S20, S2 5.
88. Up t o n D, So lo w ie j K, He n d e r C, e t a l.
Stress an d pain associated w ith
dressin g ch an ge in patien ts w ith
ch ron ic wou n ds. J Wound Care. 2012
Feb;21(2):53 54, 6,8 passim .
89. Up t o n D, St e p h e n s D, An d re w s A.
Patien ts experien ces o n egative
pressu re wou n d th erapy or th e
treatm en t o wou n ds: a review. J Wound
Care. 2013 Jan ;22(1):34 39.
90. Ho u riga n LA, Lin fo o t JA, Ch u n g KK, e t
a l. Loss o protein , im m u n oglobu lin s,
an d electrolytes in exu dates rom
n egative pressu re wou n d th erapy. Nutr
Clin Pract. 2010 Oct;25(5):510 516.
91. Sch w ie n T, Gilb e rt J, La n g C. Pressu re
u lcer prevalen ce an d th e role o
n egative pressu re wou n d th erapy in
h om e h ealth qu ality ou tcom es. Ostomy
Wound Manage. 2005 Sep;51(9):4760.

279
 Se ct io n 2Spe cial
situations
14
O pe n
wounds

280 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

 Se ctio n

Cases 3
Se ct io n 3
Case s
15 .1 Acu t e ly in fe ct e d t ib ia l n a il 19 .2 Im p la n t re m o va lin fe ct e d n o n u n io n o f t h e t ib ia
Jam e s F Ke llam 283 Jon g-Ke o n Oh 369

15 .2 Acu t e ly in fe ct e d la t e ra l m a lle o la r fra ct u re 19 .3 Im p la n t re m o va lch ro n ica lly in fe ct e d t o t a l h ip

A Sam u e l Fle m iste r Jr 289 a r t h ro p la s t y
Olivie r Bo re n s 379
15 .3 Acu t e ly in fe ct e d p ro xim a l h u m e ru s a ft e r
s o ft-t is s u e re p a ir 19 .4 Im p la n t re m o va lch ro n ic in fe ct io n a ft e r t o t a l
Matth ias A Zu m ste in 293 k n e e a rt h ro p la s t y
Craig J De lla Valle 383
15 .4 In fe ct e d t ib ia l d e la ye d u n io n w it h
b ro ke n im p la n t s 19 .5 Im p la n t re m o va lin fe ct e d t o t a l k n e e
Ch risto p h So m m e r 297 re p la ce m e n t
Ste p h e n L Kate s, Ch risto p h e r J Drin kwate r 391
15 .5 Acu t e ly in fe ct e d p ro xim a l fe m o ra l fra ct u re
d yn a m ic h ip s cre w 19 .6 Im p la n t re m o va lin fe ct e d t o t a l s h o u ld e r
Ste p h e n L Kate s 309 a r t h ro p la s t y
Arth ur Grze siak, Alain Farro n 4 01
15 .6 Acu t e ly in fe ct e d p ro xim a l fe m o ra l fra ct u re
p ro xim a l fe m o ra l n a il 19 .7 Im p la n t re m o va la cu t e ly in fe ct e d t o t a l a n k le
Mich ae l J Ze gg, Ch ristian Kam m e rlan d e r 313 a r t h ro p la s t y
Lisca Dritte n b ass, Xavie r Cre vo isie r, Math ie u Assal 4 09
16 .1 Ch ro n ica lly in fe ct e d d is t a l t ib ia l fra ct u re
Zh ao Xie 319 19 .8 Im p la n t re m o va lch ro n ica lly in fe ct e d t o t a l
e lb o w a rt h ro p la s t y
16 .2 Ch ro n ica lly in fe ct e d p ro xim a l t ib ia l fra ct u re
Anjan P Kaush ik, Joh n C Elfar 415
Zh ao Xie 325
20 Pe d ia t ric o s t e o m ye lit is
16 .3 Ch ro n ica lly in fe ct e d d is t a l fe m o ra l fra ct u re
The d dy Slon go 423
Ch an g-Wu g Oh 331
20 .1 Os t e o m ye lit is o f t h e d is t a l t ib ia
16 .4 Ch ro n ica lly in fe ct e d h ip h e m ia rt h ro p la s t y
The d dy Slon go 429
Tak-Win g Lau 337
20 .2 Os t e o m ye lit is o f t h e p ro xim a l h u m e ru s
16 .5 Ch ro n ica lly in fe ct e d d is t a l ra d ia l fra ct u re
The d dy Slon go 4 35
Pe te r JL Je bso n, David C Ring, Ge o rge SM Dye r 345
20 .3 Po s t o p e ra t ive o s t e o m ye lit is o f t h e t ib ia
17 Acu t e o s t e o m ye lit is o f t h e fe m u r
The d dy Slon go 4 43
Pe te r E Ochsne r 351
20 .4 Os t e o m ye lit is/ s e p t ic a r t h rit is o f t h e p ro xim a l
18 Ch ro n ic o s t e o m ye lit is o f t h e t ib ia
fe m u r in a t o d d le r
Pe te r E Ochsne r 357
The d dy Slon go 4 53
19 .1 Im p la n t re m o va lin fe ct e d n o n u n io n o f t h e
21 Tre a t m e n t o f in fe ct io n w it h lim it e d re s o u rce s
d is t a l h u m e ru s
Zh ao Xie 4 63
Jon g-Ke o n Oh 361
Jame s F Ke llam
15.1 Acu te ly in fe cte d tib ia l n a il
Jam e s F Ke llam
1 Ca s e d e s crip t io n
A 35-year-old m ale h elicopter m ech an ic ell rom th e top
o a h elicopter on to th e tarm ac. He h ad an open tibial
diaph yseal ractu re. His in itial treatm en t in volved adm in -
istration o a ceph alosporin an tibiotic, debridem en t o th e
open w ou n d 6 h ou rs a ter th e in ju ry, an d stabilization o
th e tibia w ith a ream ed locked n ail. At debridem en t th e
bon e w as n ot con tam in ated bu t h e h ad approxim ately 50%
o h is an terior com partm en t debrided du e to n ecrotic m u scle
rom th e in ju ry. He also h ad a 6 x 8 cm an terom edial skin
an d su bcu tan eou s de ect. It w as a Gu stilo-An derson type
IIIB open tibial ractu re. Th e patien t requ ired th ree m ore
debridem en ts w ith n egative-pressu re w ou n d th erapy over
th e n ext 2 w eeks. An ipsilateral ree latissim u s dorsi f ap
w as per orm ed at 3 w eeks a ter th e in itial debridem en t
( Fig 15 .1-1 ).
a b
Fig 15.1-1 a b X-rays of the lowe r lim b following the initial
de bride m e nt and nailing.
a AP vie w.
b Late ral vie w.
2 In d ica t io n s
Tw o w eeks ollow in g th e f ap coverage, th e patien t h ad
n ecrosis o th e split-th ickn ess skin over th e f ap an d th e f ap
w as o qu estion able viability. Th e f ap w as regra ted w ith
split-th ickn ess skin an d observed. At th is tim e h is oot w as
plan tigrade, h e h ad n o vascu lar in su cien cy, an d sen sation
an d m otor u n ction to th e oot w ere n orm al. He presen ted
at 8 w eeks rom h is in ju ry w ith clou dy drain age em an atin g
rom u n der th e ree f ap. Th e f ap w as viable an d th e skin
gra t h ad taken com pletely. His x-rays sh ow ed som e rac-
tu re-site bon y resorption bu t n o eviden ce o h ealin g
( Fig 15 .1-2 ). Th e w h ite blood cell cou n t w as elevated w ith a
le t sh i t; th e eryth rocyte sedim en tation rate w as 80 m m / h
(n orm al ran ge: 023 m m / h ), an d C-reactive protein w as
4.2 m g/ L (n orm al ran ge: less th an 5 m g/ L). He w as a ebrile
bu t elt gen erally u n w ell. Cu ltu res w ere de erred in avor
o a deep biopsy or tissu e cu ltu re.
a b
Fig 15.1-2a b X-rays of the lowe r le g at the tim e of drainage from
the ap. The fracture appe ars to be re sorbing, which is indicative of
an infe ctive proce ss.
a Late ral vie w.
b Inte rnal rotation oblique vie w.
283
 Se ct io n 3Case s
15.1Acute ly
infe cte d
tibial
nail

3 Pre o p e ra t ive p la n n in g 4 Su rgica l a p p ro a ch

Th e patien t w ill n ot receive an y preoperative an tibiotics so Th e prior ractu re site w as approach ed by elevatin g th e f ap
th e preoperative sta an d an esth etists n eed to be n oti ed based on its vascu lar pedicle. Th e n ail w as rem oved th rou gh
th at th is is an in ected case an d cu ltu res w ill be taken th e previou s m edial parapatellar in cision an d th e lockin g
in traoperatively. A radiolu cen t operative table is n eeded. A screw rem oved th rou gh th e old stab w ou n ds.
tou rn iqu et is placed on th e th igh bu t n ot in f ated du e to th e
poten tial or h eat n ecrosis du rin g in tram edu llary (IM) can al
ream in g. Stan dard operative sterile preparation o th e skin 5 Su rgica l d e b rid e m e n t
w ill be u sed. Prior to en terin g th e room , th e IM n ail re-
m oval equ ipm en t is ch ecked to en su re it is com plete. A 32 Th e patien t u n derwen t re-exploration : th e f ap was elevated
Fren ch ch est tu be, ball-tipped ream in g gu ide, tw o packs o on its pedicle. Th e ractu re site w as debrided an d specim en s
polym eth ylm eth acrylate (PMMA), an d 2 g o gen tam icin rom bon e, brou s ractu re-site tissu e, an d m u scle w ere
pow der m u st be presen t in th e operatin g room . Th e patien t taken or cu ltu re. Th e bon e en ds w ere debrided o an y n e-
is prepared an d draped in a stan dard ash ion . Th e n ail is crotic n on bleedin g bon e. It w as n oted th at th ere w as pu s
rem oved th rou gh th e prior in cision s. Th e can al is ream ed trackin g u p an d dow n th e m edu llary can al. Th is in dicated
to tw o sizes above th e n ail rem oved. Th e prior distal lockin g th at th e IM can al w as con tam in ated by th e in ection an d
screw h oles w ill act as ven ts or th e ream in gs. A ter ream in g w ou ld requ ire a debridem en t by IM ream in g.
th e can al, it is irrigated w ith salin e solu tion u sin g a total h ip
IM irrigator aspirator to en su re th at all th e debris rom th e
m ost cau dal part o th e ream in g tract is rem oved. Th e PMMA
n ail (see below ) is m ade an d in serted. Th e gu ide w ire is cu t
at th e en try to th e IM can al an d ben t past a righ t an gle to
preven t it rom allin g in to th e can al. Th e in cision is closed
an d th e leg splin ted. Postoperatively th e leg w ill be placed
in a sh ort leg cast an d th e patien t allow ed to bear w eigh t as
tolerated.

Vid e o 15.1-1 Pre paring an antibiotic-loade d ce me nt nail for the tibia.

284 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jame s F Ke llam
6 Im p la n t re m o va l a n d t e m p o ra r y fixa t io n
Th e in tram edu llary n ail w as rem oved, th e can al ream ed
2 m m above th e n ail size an d th orou gh ly irrigated w ith
salin e u sin g a total h ip m edu llary irrigator aspirator. Usin g
th e largest ch est tu be (32F) an d a beaded ream in g gu ide
w ire in serted in to th e ch est tu be, it w as lled w ith PMMA
w ith 2 g o gen tam icin an d allow ed to solidi y ( Vid e o 15.1-1 ).
On ce h ard, th e ch est tu be w as cu t aw ay an d th e PMMA n ail
in serted in to th e m edu llary can al to provide som e ractu re
stability an d deliver local an tibiotics ( Fig 15 .1-3 ). Th e f ap
w as replaced an d closed. Th e tissu e cu ltu res grew m eth icil-
lin -resistan t Staphylococcus aureus sen sitive to van com ycin .
a b
Fig 15.1-3a b X-rays of the lowe r le g following nail re m oval, re am ing, de bride m e nt,
and the inse rtion of an antibiotic polym e thylm e thacrylate nail.
a AP vie w.
b Late ral vie w.
7 Po s t o p e ra t ive m a n a ge m e n t (1)
Th e in ectiou s diseases ph ysician w as con su lted to h elp m an -
age th e in ection m edically. Th e in ectiou s diseases specialist
recom m en ded 1 g o van com ycin in traven ou sly tw ice daily
or 6 w eeks. A percu tan eou s in traven ou s cen tral cath eter
w as in serted or th e delivery o an tibiotics. Th e w ou n d w as
ch ecked an d th e lower leg placed in a patellar ten don -bearin g
cast to allow w eigh t bearin g as tolerated. At 2 w eeks th e
cast w as rem oved, th e f ap w as viable, an d th e in cision h ad
h ealed. Th e low er leg rem ain ed in th e patellar ten don -
bearin g cast. At 6 w eeks th e eryth rocyte sedim en tation rate
an d C-reactive protein h ad retu rn ed to n orm al an d th e
in cision h ad n o drain age an d w as h ealed.
285
 Se ct io n 3Case s
15.1Acute ly
infe cte d
tibial
nail

8 Re im p la n t a t io n 9 Po s t o p e ra t ive m a n a ge m e n t (2)

Th e patien t h ad th e PMMA n ail rem oved, th e can al ream ed, Postoperatively, th e patien t w as allow ed to bear w eigh t as
an d a static locked IM n ail in serted ( Fig 15 .1-4 ). Th e ream in gs tolerated. Th e cu ltu re w as n egative or grow th . At 2 w eeks
w ere sen t or cu ltu re. Follow in g n ailin g, an an terior iliac th e in cision s w ere h ealed w ith n o u rth er drain age.
crest au togen ou s can cellou s bon e gra t w as in serted by th e
cen tral tech n iqu e. Th is tech n iqu e exposes th e lateral aspect
o th e tibia an terior to th e in term u scu lar m em bran e, w h ich
is excised rom its tibial in sertion to allow th e bon e gra t to
be placed posteriorly to th e tibia as w ell as lateral an d ex-
ten din g to th e bu la [1, 2].

a b c

Fig 15.1-4a c X-ray of the lowe r le g nail at 6 we e ks following antibiotic polym e thylm e thacrylate nail and the inse rtion of an ne w
statically locke d nail.
a AP vie w.
b Inte rnal oblique vie w.
c Late ral vie w.

286 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jame s F Ke llam

10 Ou t co m e 13 Re fe re n ce

By 5 m on th s postoperatively, th e patien t w as bearin g u ll
w eigh t an d retu rn ed to h is job as a h elicopter m ech an ic
( Fig 15 .1-5 ).
1. Ryze w icz M, Mo rga n SJ, Lin fo rd E, e t a l . Cen tral bon e gra tin g
or n on u n ion o ractu res o th e tibia: a retrospective series.
J Bone Joint Surg Br. 2009 Apr;91(4):522529.
2. Rijn b e rg W.J. a n d Va n Lin ge B. Cen tral gra tin g or persisten t
n onu n ion s o th e tibia. J Bone Joint Surg (Br) 1993; 75B:926 931.

11 Pit fa lls

Th e delay in obtain in g viable coverage in creased risk

or in ection .
Th e ailu re to appreciate th e poten tial issu e w ith f ap
coverage led to w ou n d breakdow n an d in ection .

12 Pe a rls

Adm in istration o an tibiotics as soon as possible rom

th e tim e o in ju ry.
Th orou gh assessm en t o th e w ou n d an d aggressive
debridem en t.
Mu st ach ieve early (w ith in 35 days) coverage o th e
w ou n d.
Recogn ition o f ap problem s early dem an ds an
aggressive respon se su ch as redebridem en t an d
assessm en t or revision o coverage.

a b c
Fig 15.1-5a c X-rays at 5 m onths following re am ing and cance llous
bone grafting via the ce ntral route .
a AP vie w.
b Inte rnal rotation oblique vie w.
c Late ral vie w.

287
 Se ct io n 3Case s
15.1Acute ly
infe cte d
tibial
nail

288 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

A Samuel Fle mister Jr

15.2 Acu te ly in fe cte d la te ra l m a lle o la r fra ctu re

A Sam u e l Fle m iste r Jr

1 Ca s e d e s crip t io n 2 In d ica t io n s

A 66-year-old m an w ith a h istory o rh eu m atoid arth ritis Relatively u rgen t su rgical debridem en t w as in dicated to avoid
presen ted w ith a 3-day h istory o in creased pain , redn ess, sepsis an d decom pen sation . Th e patien t w as elderly an d
an d w arm th abou t th e lateral aspect o th e righ t an kle. Th e im m u n ocom prom ised. He presen ted w ith a drain in g w ou n d
patien t den ied an y evers, ch ills, or n igh t sw eats. Th e patien t th at w as obviou sly in ected. Laboratory stu dies revealed an
h ad u n dergon e open redu ction an d in tern al xation or an eryth rocyte sedim en tation rate o 78 m m / h (n orm al ran ge:
an kle ractu re 2 years be ore ( Fig 15 .2-1). Eigh t m on th s a ter 023 m m / h ), w h ite blood cell (WBC) cou n t 8,700 (n orm al
th e in itial operation , th e patien t h ad th e lateral plate an d ran ge: 4,00010,000 cells/ L), an d C-reactive protein 27
screw s rem oved secon dary to a drain in g w ou n d. Tw o broken m g/ L (n orm al ran ge: less th an 5 m g/ L). Alth ou gh th ese
syn desm otic screw s w ere n ot rem oved rom th e tibia m arkers w ere n ot very elevated given th e patien ts relative
( Fig 15 .2-2 ). Cu ltu res taken at th at tim e revealed m eth icillin - im m u n ocom prom ised state, th ey w ere elt to be sign i can t.
sen sitive Staphylococcus aureus. Th e patien t h ad been treated
w ith oral an tibiotics con sistin g o ceph alexin 500 m g orally
ou r tim es per day an d trim eth oprim / su l am eth oxazole
dou ble stren gth 500 m g orally tw ice per day. Th e patien t
h ad n ot h ad an y problem s w ith th e w ou n d or th e an kle
sin ce th e tim e o th is h ardw are rem oval. Th e patien t h ad
recen tly started u se o etan ercept an d predn ison e to treat
h is rh eu m atoid arth ritis.

a b a b
Fig 15.2-1a b Vie ws of the ankle prior to late ral plate re m oval. Fig 15.2-2a b Vie ws of the ankle at pre se ntation.
a AP vie w. a AP vie w.
b Late ral vie w. b Late ral vie w.

289
 Se ct io n 3Case s
15.2Acute ly
infe cte d
late ral
malle olar
fracture
3 Pre o p e ra t ive p la n n in g
Th is im m u n ocom prom ised patien t w as adm itted to th e
h ospital an d started on am picillin / su lbactam 1.5 g in trave-
n ou sly every 6 h ou rs. A radiolabeled WBC scan su ggested
a ocu s o osteom yelitis in th e bu la ( Fig 15 .2-3 ). Both bon e
debridem en t an d rem oval o residu al h ardw are w ere plan n ed.
A broken -screw rem oval set w as m ade available.
4 Su rgica l a p p ro a ch
Th e patien t was placed in th e su pin e position with a san dbag
u n der th e ipsilateral h ip. Th e previou s lateral in cision w as
u sed. An tibiotics h ad been adm in istered on th e sch edu le
determ in ed at th e tim e o adm ission . A pn eu m atic tou rn iqu et
w as applied to th e th igh bu t n ot in f ated. Th e patien t w as
given a gen eral an esth etic. Th is w as h is th ird operation in
th is area so sign i can t scarrin g w as an ticipated. Care w as
taken to avoid in ju ry to th e su per cial peron eal n erve an d
m ain tain u ll-th ickn ess skin f aps.
Fig 15.2-3 Tagge d white blood ce ll scan of the ankle s.
290
5 Su rgica l d e b rid e m e n t
Th e skin edges an d su bcu tan eou s tissu e associated w ith th e
drain in g w ou n d w ere excised. All n ecrotic-appearin g so t
tissu e w as rem oved. Th e w ou n d w as th en irrigated w ith
n orm al salin e solu tion . Th e tagged WBC scan h ad isolated
an area o osteom yelitis to th e m ost proxim al syn desm otic
screw h ole. Th is area w as overdrilled w ith a h ollow core
ream er an d th e screw h ole cored ou t. Th e rem ain der o th e
bon e w as th en in spected or an y com prom ised areas an d
debrided as n eeded. On ce adequ ate debridem en t an d re-
m oval o h ardw are h ad been accom plish ed, th e w ou n d w as
on ce again irrigated an d th en loosely closed w ith a sin gle
layer o n ylon su tu re.
6 Im p la n t re m o va l
A cen terin g gu ide w as placed th rou gh th e origin al syn des-
m otic screw h ole in th e bu la an d passed to th e adjacen t
screw h ole in th e tibia u n til it en gaged th e broken screw . A
h ollow ream er sligh tly larger th an th e screw w as th en placed
over th e cen terin g gu ide an d th e cen terin g gu ide w ith draw n .
Th e ream er w as u sed to overdrill th e screw . Th is perm itted
placem en t o an extraction bolt over th e screw or rem oval.
7 Te m p o ra r y fixa t io n
No tem porary xation w as requ ired given th at adequ ate
stability rem ain ed a ter resection o a com prom ised area o
th e bu la.
8 Po s t o p e ra t ive m a n a ge m e n t
Th e patien t w as placed in to a rem ovable sh ort leg splin t an d
kept n on w eigh t bearin g or approxim ately 2 w eeks u n til
th e w ou n d h ad h ealed. Th e w ou n d w as in spected every 1
or 2 days to be m on itored or resolu tion o in ection . A ter
2 w eeks h e w as th en allow ed to bear w eigh t as tolerated in
a regu lar sh oe th at w ou ld n ot irritate th e w ou n d. A com -
pressive stockin g w as u sed to redu ce edem a. An in ectiou s
diseases ph ysician w as con su lted or advice. Su rgical cu ltu res
again grew m eth icillin -sen sitive S aureus an d th e patien t
received a 6-w eek cou rse o in traven ou s ce azolin (1 g every
8 h ou rs).
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
A Samuel Fle mister Jr
9 Re im p la n t a t io n
No im plan t w as requ ired as th e ractu re h ad h ealed.
10 Ou t co m e
Th e w ou n d h ealed w ell an d th e in f am m atory m arkers de-
creased. Th e patien t even tu ally developed sign i can t an kle
arth rosis du e to a com bin ation o posttrau m atic osteoarth ri-
tis an d rh eu m atoid arth ritis versu s in ection ( Fig 15 .2 -4 ).
How ever, th e patien t also developed periph eral n eu ropath y
an d h ad a m in im al am ou n t o pain . Th ere ore, n o u rth er
su rgery w as requ ired.
a b
Fig 15.2-4a b Final vie ws of the ankle .
a AP vie w.
b Late ral vie w.
11 Pit fa lls
In th is case, m akin g an accu rate diagn osis o th e
am ou n t o bon e th at n eeded to be resected w as
essen tial. Un derresection o in ected bon e w ou ld lead
to recu rren t problem s an d overresection cou ld possibly
cau se in stability n ecessitatin g an kle arth rodesis.
Th is case illu strates th e im portan ce o rem ovin g all
h ardw are in cases o in ection .
12 Pe a rls
Advan ced im agin g su ch as th e com bin ation o bon e
scan an d labeled WBC scan can h elp to localize th e
in volved areas o osteom yelitis an d h elp gu ide th e
su rgical approach .
All in ected h ardw are sh ou ld be rem oved especially i
th e ractu res are h ealed.
Tem porary xation is requ ired i in stability develops.
Cu ltu re-speci c an tibiotics sh ou ld be u sed or an
adequ ate len gth o tim e to eradicate th e in ection .
An in ectiou s diseases con su ltan t is an im portan t team
m em ber.
I en ou gh resection o th e bu la w as requ ired th at th e
tibiotalar join t becam e u n stable, th en an an kle arth rod-
esis w ou ld be requ ired.
291
 Se ct io n 3Case s
15.2Acute ly
infe cte d
late ral
malle olar
fracture

292 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Matthias A Zumstein

15.3 Acu te ly in fe cte d p roxim a l h u m e ru s a fte r

s o ft-tis su e re p a ir
Matth ias A Zu m ste in

1 Ca s e d e s crip t io n 2 In d ica t io n s

A 66-year-old m an com plain ed o a 3-day h istory o an acu te Th e sym ptom s o acu te pain com bin ed with th ese laboratory
on set o pain an d in creased sti n ess in h is righ t sh ou lder. an d radiograph ic in din gs stron gly su ggested an acu te
Fou r w eeks previou sly h e h ad u n dergon e rotator-cu repair su rgical-site in ection in volvin g th e an terolateral portal an d
w ith an arth roscopic procedu re or an acu te trau m atic tear bon e o th e proxim al h u m eru s. Hen ce, th e decision or an
o th e rotator-cu ten don s. He h ad n o ever, ch ills, or m al- arth roscopic debridem en t w as taken . Addition ally, th e po-
aise. On clin ical exam in ation th ere w as n o in dication o an ten tial or su bsequ en t in terven tion s was discu ssed, depen din g
in ection (eg, w arm th , eryth em a). Th e C-reactive protein on th e exten t o in traoperative n din gs an d m icrobiological
(CRP) w as elevated at 223 m g/ L (n orm al ran ge: less th an 5 resu lts.
m g/ L), as w as th e w h ite blood cell cou n t (WBC) at 12.5 g/ L
(n orm al ran ge: 410 g/ L). A m agn etic reson an ce im agin g
( Fig 15.3-1 ) in clu din g in traven ou s con trast application sh ow ed
m u ltiple-f u id collection s alon g th e an terosu perior portal,
in volvin g th e join t an d th e bon e o th e proxim al h u m eru s.
Syn ovial f u id leu kocyte cou n t sh ow ed 25 x 10 9 / L w ith 80%
n eu troph ils.

a b
Fig 15.3-1a b Pre ope rative m agne tic re sonance im age s.
a Contrast axial vie w.
b Contrast coronal vie w.

293
 Se ct io n 3Case s
15.3Acute ly
infe cte d
proximal
humerus
after
soft-tissue
re pair
3 Pre o p e ra t ive p la n n in g
Th e m ost im portan t poin t to discu ss in th is section is th e
am ou n t o debridem en t n ecessary an d rem oval o im plan ts.
Th e au th or su spected an acu te in ection o th e su bacro-
m ial bu rsa, th e join t, an d th e bon e. Com plete syn ovectom y,
rem oval o all su tu re m aterial an d an ch ors, i easily easible,
w ere plan n ed. How ever, i th e an ch ors w ere deeply xed
in th e bon e, th ey w ou ld h ave n ot been rem oved du e to th e
possible osseou s dam age.
A stan dard arth roscopic setu p w as ch osen w ith a beach -ch air
position in clu din g a lim b position er ( Fig 15.3-2 ). Arth roscopic
scissors w ere prepared to cu t th e su tu res, an d closed as w ell
as open clam ps w ere prepared to rem ove tissu e.
No an tibiotics w ere given to th e patien t prior to m icrobio-
logical sam plin g. Gen eral an esth esia w as ch osen in th is case.
Fig 15.3-2 A standard arthroscopic se tup was chose n with a be ach-
chair position including a lim b positione r.
294
4 Su rgica l a p p ro a ch
Stan dard posterior, an terom edial, an terolateral, an d lateral
portals w ere ch osen to address all areas o th e sh ou lder
in traarticu larly an d su bacrom ially ( Fig 15 .3 -3 ).
Th e su rgeon starts w ith th e posterior portal, w h ich sh ou ld
be con du cted w ith th e arm in in tern al rotation to pen etrate
th e m u scle bers an d n ot th e ten don . Th e au th or pre ers to
m ake th e portals ou tside to con trol th e an gles an d th e
accessibility w ith th e in stru m en ts. Altern atively an d espe-
cially in case o excessive in f am m ation an d in adequ ate
in traarticu lar vision , th e an terom edial portal can be m ade
in side ou t u sin g a sw itch in g stick.
Anteromedial
portal
Posterior
portal
Anterolateral
portal
Lateral
portal
Fig 15.3-3 Portals for surgical approach.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Matthias A Zumstein
5 Su rgica l d e b rid e m e n t
5 .1 In t ra a r t icu la r d e b rid e m e n t (s yn o via l a n d
o p t io n a l ca p s u le )
A ter establish in g th e posterior an d an terom edial portals, a
m eticu lou s in traarticu lar syn ovectom y an d debridem en t
sh ou ld be m ade. Startin g rom an terosu perior by rem ovin g
th e rotator in terval u n til th e su bscapu laris ten don in eriorly
an d th e coracoh u m eral ligam en t su periorly, th e syn oviu m
can be resected easily u n til th e in erior 6 oclock position .
Usin g a sw itch in g stick, th e bu rsa below th e coracoid can
be dissected to be su re th at th ere is n o abscess in th e su b-
coracoid bu rsa. Atten tion sh ou ld be paid at th e m edial border
below th e acrom ion as th e acrom ial bran ch o th e th ora-
coacrom ial artery em erges m edially.
I th ere are poten tial abscesses in th e su bscapu lar ossa, th is
area is rin sed by spreadin g th e layer betw een th e m iddle
glen oh u m eral ligam en t an d th e glen oid labru m u sin g th e
sw itch in g stick an d goin g dow n in to th e ossa. Th en , th e
scope an d th e w orkin g in stru m en ts are sw itch ed an d th e
syn ovectom y is com pleted posteriorly an d posteroin eri-
orly. Again , in case o abscesses in th e ossa in raspin ata,
th e sam e procedu re can be per orm ed posteriorly w ith a
sw itch in g stick goin g in betw een th e labru m an d th e capsu le
in ron t o th e in raspin atu s.
Th e au th or ten otom izes th e lon g h ead o th e biceps i it is
n ot yet per orm ed by th e previou s in terven tion . Th ere is n o
eviden ce th at patien ts h ave n egative side e ects ollow in g
ten otom y or ten odesis o th e lon g h ead o th e biceps at
m idterm . In case o a partially or totally h ealed ten don o
th e posterosu perior cu an d i th ere are su tu res visible th at
cam e ou t o th e m edial an ch ors, th e au th or pre ers to cu t
th em at th is stage. Altern atively an d w ith ou t h ealin g, th e
su tu res can be easily cu t rom th e lateral view .
5 .2 Su b a cro m ia l d e b rid e m e n t (b u rs a , a d h e s io n s )
A ter pu ttin g th e scope in th e lateral portal an d establish in g
th e an terolateral portal by trian gu lation an d th e h elp o a
spin al n eedle, a com plete su bacrom ial bu rsectom y is per orm ed
u n til th e spin e o th e scapu la an d th e com plete acrom ion is
visible. An teriorly th e coracoacrom ial ligam en t can be in -
cised, excised to gain u ll access to th e an terior com partm en t.
I n eeded, th e tran sverse ligam en t can be in cised to debride
poten tial abscesses in th e bicipital groove.
6 An ch o r re m o va l
Th e au th or decided to rem ove all th e su tu res. Th is w as don e
by cu ttin g th e m edial su tu res du rin g th e in traarticu lar ar-
th roscopy. How ever, com plete rem oval o th e su tu res w as
per orm ed rom th e su bacrom ial approach . As th e ten don
w as partially h ealed to th e greater tu berosity, th e au th or
rem oved on ly th e lateral an ch ors. Th is w as m ade w ith th e
arm in abdu ction to access th e an ch ors recess w ith a con ical
extraction screw . A ter placin g th e tip o th e con ical extrac-
tion screw in to th e an ch ors recess, it is h eld as vertical as
possible an d a gen tle tappin g on th e extraction screw is
m ade. Tu rn it cou n terclockw ise, exertin g pressu re, u n til th e
extraction screw grasps in to th e an ch or an d con tin u e to tu rn
cou n terclockw ise to rem ove th e an ch or.
A ter rem ovin g all im plan ts, em piric in traven ou s an tim i-
crobial th erapy (am oxicillin / clavu lan ate 2.2 g every 6 h ou rs)
w as started im m ediately.
7 Te m p o ra r y fixa t io n
Th e m ost an terior part (3 m m w idth ) o th e ten don o th e
rotator cu h ad n ot com pletely reattach ed to th e greater
tu berosity. As m in or cu lesion s m ay n ot predispose to u r-
th er ten don retraction , atty in ltration , an d atroph y, n or
to in erior clin ical resu lts, n o addition al im plan ts w ere u sed.
8 Po s t o p e ra t ive m a n a ge m e n t
Im m ediately postoperatively, th e arm w as protected in a
slin g du rin g th e day an d a Gilch rist ban dage at n igh t. Tw o
days postoperatively, Staphylococcus aureus grew rom all
sam ples. Th e in traven ou s treatm en t w as ch an ged to f u -
cloxacillin (2 g every 6 h ou rs) or a u rth er 5 days (ie, total
in traven ou s treatm en t 7 days). A ter th e w ou n ds w ere dry,
an d th e CRP h ad allen to 5 m g/ L, th e an tim icrobial treat-
m en t w as sw itch ed to oral ri am pin (450 m g tw ice daily)
an d levof oxacin (500 m g tw ice daily) or a total treatm en t
du ration o 3 m on th s.
Mobilization w as allow ed w ith ou t restriction im m ediately
postoperatively. Th e postoperative cou rse w as u n even t u l,
as w ere ollow -u p in vestigation s a ter 6 an d 12 w eeks.
295
 Se ct io n 3Case s
15.3Acute ly
infe cte d
proximal
humerus
after
soft-tissue
re pair

9 Ou t co m e 11 Pe a rls

At th e 6-m on th ollow -u p, th e patien t w as very satis ed 11.1 Su rgica l a p p ro a ch

w ith th e n al resu lt. A ter in ten sive reh abilitation , h is ex-
am in ation sh ow ed f exion o 160, active extern al rotation
o 50, an d in tern al rotation at L5.
10 Pit fa lls
Particu lar pit alls to avoid in clu de per orm in g arth roscopic
debridem en t on h em iarth roplasty, total sh ou lder replace-
m en t, or reverse sh ou lder replacem en t join ts. It is also a
con train dication to m an age a sh ou lder w ith arth roscopic
treatm en t i bon y in volvem en t is n oted on preoperative
im agin g. Relative con train dication s to th is procedu re w ou ld
be patien ts in w h om th e desired position in g or sh ou lder
arth roscopy is n ot possible.
Both arth roscopic an d open su rgery are option s or a com plete
debridem en t o th e sh ou lder. How ever, th e au th ors believe
th ey can address m ore precisely all areas w ith in th e join t as
w ell as th e ossa su bscapu laris an d th e ossa in raspin ata
u sin g an arth roscopic procedu re. All view in g an d w orkin g
portals can be sw itch ed in both th e su bacrom ial as w ell as
th e in traarticu lar space so th ere ore all option s are possible.
Fu rth erm ore, goin g ar posterior in th e su bacrom ial space is
less di cu lt w ith an arth roscopic procedu re. On ly experi-
en ced sh ou lder arth roscopists sh ou ld per orm th is su rgery.
11.2 Im p la n t re m o va l
Th is case is a typical debridem en t an d im plan t reten tion
case: th is treatm en t option is m ain ly con sidered in acu te
in ection s w ith a sh ort du ration o sym ptom s, an d in early
postoperative in ection s. Th e ollow in g prin ciples are es-
sen tial or su ch a case:

Su rgery m u st be per orm ed rapidly.

Irrigation an d debridem en t sh ou ld be m eticu lou s, an d
are easily per orm ed by arth roscopy.
Mobile elem en ts, su ch as su tu res, sh ou ld be rem oved.
Th e so t-tissu e dam age is n ot severe (eg, sin u s tract or
m u ltiple or large abscess an d n ecrotic m aterial).
Th ere is absen ce o a di cu lt-to-treat path ogen (eg,
ri am pin -resistan t staph ylococci, u n gi).

With correct patien t selection , th e ou tcom e o th is procedu re

h as been reported to be good w ith an in ection - ree in terval
ran gin g rom 85% to 100% .

296 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Christoph Somme r

15.4 In fe cte d tib ia l d e la ye d u n io n w ith b ro ke n

im p la n ts
Ch risto p h So m m e r

1 Ca s e d e s crip t io n sm all articu lar com pon en t ( Fig 15 .2 -2 a ), w h ich w as com -

A 23-year-old driver w as in volved in a car crash an d su stain ed
a grade IIIA open in traarticu lar distal low er-leg ractu re
(pilon ractu re) AO/ OTA Classi cation 43-C3 ( Fig 15 .4 -1 ).
Th e rst step in su rgery con sisted o in itial debridem en t o
th e w ou n d, revealin g a large m etadiaph yseal ragm en t w ith
pletely detach ed rom th e so t tissu e an d th ere ore avascu lar.
Du e to on ly m in im al con tam in ation , th is ragm en t w as
clean ed an d preserved in th e re rigerator at 4 C. Th e rac-
tu re w as stabilized w ith a join t-bridgin g extern al xator
( Fig 15 .4-2b ). A postoperative com pu ted-tom ograph ic (CT)

a b

c b
15.4-1a c Initial x-rays afte r the accide nt 15.4-2a b Initial ope ration 2 hours afte r
showing a pilon fracture with a re lative ly sim ple adm ission.
fracture patte rn, but m assive ly displace d and a Re m ove d and te m porarily pre se rve d large
large ante rolate ral articular fragm e nt. e pim e tadiaphyse al fragm e nt.
a AP vie w. b Ankle bridging e xte rnal xator and
b Late ral vie w. partially ope n wound tre atm e nt, late ral.
c Clinical aspe ct from late ral showing the
wound at the le ve l of the bula fracture .

297
 Se ct io n 3Case s
15.4
Infe cte d
tibial
delaye d
union
with
broke n
im plants

scan w as u sed or u rth er plan n in g ( Fig 15 .4 -3 ). Tw o days
later a secon d look w ith irrigation w as per orm ed, an d 5
days later de n itive recon stru ction w as accom plish ed u sin g
a sm all posterom edial approach or redu ction an d an tiglide
plate xation o th e diaph yseal com pon en t ( Fig 15.4 -4 a ), an d
a prim ary lateral exten ded approach or articu lar recon stru c-
tion an d xation . Th e large preserved bon e ragm en t w as
rein serted, an atom ically redu ced, an d rigidly xed u sin g lag
screw s an d a n eu tralization plate ( Fig 15.4-4b d ). Postopera-
tive x-rays dem on strated correct align m en t an d h ardw are
position o th e open redu ction an d in tern al xation
( Fig 15 .4 -5 ). Wou n d h ealin g w as u n even t u l an d th ere w ere
n o sign s o in ection a ter 6 w eeks ( Fig 15 .4 -6 ).

a b

15.4-3 Com pute d tom ographic

scan afte r the initial ope ration
re ve als the fracture patte rn and
shows the large bone de fe ct,
ante rolate ral.

c d
15 .4 -4 a d De nitive re construction of the bone 7 days afte r injury.
a Small poste rom e dial incision at the le ve l of the distal diaphysis with sm all
antiglide plate .
b Pre se rve d ante rolate ral fragm e nt be fore re im plantation.
c Late ral e xte nde d approach de m onstrating the late ral de fe ct with corre sponding
fragm e nt.
d Large fragm e nt re duce d and xe d with lag scre ws. Plate xation of the bula.

a b a b
15.4-5 a b Postope rative x-rays 15.4 -6 a b Soft-tissue situation 6 we e ks afte r injury shows a cle an and calm situation
showing an anatom ical re construction without any signs of infe ction.
with stable plate xation of the tibia a Late ral aspe ct.
and bula. b Me dial aspe ct.
a AP vie w.
b Late ral vie w.

298 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Christoph Somme r
Th ree an d a h al m on th s a ter in ju ry, th e plate broke
( Fig 15.4 -7 ) an d th e patien t w as readm itted. Th e posterom e-
dial w ou n d w as sligh tly in f am ed su ggestin g a possible low -
grade in ection in th e diaph yseal region . Clin ically th ere
w ere n o sign s o articu lar in ection an d n o in traarticu lar
e u sion w as detected by son ograph y. Th e C-reactive protein
(CRP) level w as n orm al (4.0 m g/ L). Th e clin ical diagn osis
o a delayed u n ion w ith im plan t ailu re du e to a bon e
vascu larity problem (w ith possible low -grade in ection ) w as
m ade.
2 In d ica t io n s
Delayed u n ion in a case o im plan t ailu re in th e distal
tibia 4 m on th s a ter in itial m an agem en t is a clear in dication
or su rgical treatm en t. Du e to th e low in dex o su spicion
clin ically (n o redn ess, on ly m in im al sw ellin g, an d w arm th
o th e skin ), n orm al CRP level, an d n o radiograph ic sign s
o a deep in ection , n o u rth er diagn ostic stu dies w ere per-
orm ed prior to reoperation .
a b
15.4-7 a b X-rays 3 .5 m onths afte r injury, 2 we e ks afte r
the patie nt starte d full we ight be aring.
a AP vie w.
b Late ral vie w.
3 Pre o p e ra t ive p la n n in g
A staged procedu re w as plan n ed. Th e rst step con sisted o :
Rem oval o th e ailed im plan ts (lateral plate an d screw s
o th e m edial tibial plate, bu lar plate)
Bon e debridem en t as n ecessary w ith several biopsies
or cu ltu res
Fractu re stabilization (tibia an d bu la) based on th e
in traoperative n din gs
Fixation option s in clu ded an extern al xator, or a com bin ation
w ith on e or several plates.
A ter th is rst step, a broad-spectru m an tibiotic proph y-
laxis w as plan n ed u n til th e de n itive m icrobiological resu lts
w ere available. As an addition al step, bon e gra tin g seem ed
to be n ecessary.
Th e patien t w as position ed su pin e w ith a pillow u n der th e
le t bu ttock ( Fig 15.4-8 ). A th igh tou rn iqu et w as placed an d
in f ated at th e begin n in g to perm it better in spection o th e
operative eld an d to decide i an y sign s o an in ection w ere
presen t. Du rin g su rgery, a ter in itial debridem en t, th e
tou rn iqu et w as def ated to ju dge th e vitality o th e rem ain -
in g bon e to decide i u rth er bon e debridem en t m igh t be
n ecessary.
15.4-8 Positioning for re ope ration: supine with a pillow unde r the
le ft buttock.
299
 Se ct io n 3Case s
15.4
Infe cte d
tibial
delaye d
union
with
broke n
im plants

4 Su rgica l a p p ro a ch an terolateral plate w as m obilized an d rem oved. Th is ap-

To rem ove th e ailed im plan ts an d to in spect an d debride
th e delayed u n ion zon e, both old in cision s (an terolateral as
prim ary an d posterom edial as secon d sm aller approach es)
w ere open ed. Th e an terolateral (exten ded) approach ol-
low ed th e an terior border o th e bu la w ith a sligh t an te-
rior cu rve distally to exten d 45 cm over th e an terolateral
an kle join t ( Fig 15.4-4d , Fig 15.4-9 a b ). Th e su perior exten sor
retin acu lu m an d ascia w ere in cised lon gitu din ally ju st in
ron t o th e ibu la. Elevation o th e exten sor ten don s/
m u scles perm its su rgical exposu re o th e an terolateral part
o th e tibia. At join t level, th e an terolateral edge (tu bercle
o Tillau x-Ch apu t) o th e tibia w ith th e in tact an terior
syn desm otic ligam en t is visu alized. Th e distal part o th e
proach perm its exposu re o 8 cm o th e distal tibia. Fu rth er
proxim ally, th ere exists a taboo zon e ( Fig 15.4-9a ) becau se
at th at level th e n eu rovascu lar bu n dle (an terior tibial artery
an d vein an d deep peron eal n erve) crosses th e distal tibia
rom proxim al posterior to distal an terior an d th ere ore is
in dan ger. A sm all separate an terolateral stab in cision m ore
proxim ally at th e level o th e proxim al part o th e plate is
u sed to deliver th ese im plan ts (visible at th e en d o th e
operation in Fig 15.4-9f ). For th e m edial plate, a sm all pos-
terom edial approach at th e level o th e existin g plate w as
per orm ed. Th e approach exposes th e posterom edial edge
o th e tibia in a straigh t orw ard w ay w ith ou t en dan gerin g
an y vital stru ctu res (visible at th e en d o th e operation in
Fig 15 .4 -9 g ).

a
b Anterolateral (extended) Anterolateral (stab)
c approach approach

a
Taboo zone b

Fig 15.4-9 a c First re vision surge ry afte r plate bre akage ,

3 .5 m onths afte r initial injury.
a Pre ope rative plan.
b First aspe ct from late ral re ve aling the large re im plante d,
avascular m e tadiaphyse al fragm e nt of the tibia.
c Afte r subtotal re m oval of this fragm e nt, le aving the articular
part of the fragm e nt in situ (the distal e nd of the se gm e ntal
re se ction).

300 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Christoph Somme r

5 Su rgica l d e b rid e m e n t , im p la n t re m o va l, a n d au th or decided to excise th e en tire in volved bon e segm en t

t e m p o ra r y fixa t io n
A ter rem oval o th e broken lateral tibial plate distally, th e
in itially reim plan ted large osseou s ragm en t ( Fig 15.4 -4 b d )
w as clearly visible as w h ite, avascu lar cortical bon e ( Fig
15.4-9 b ). On th e lateral side, n o sign s o an in ection w ere
n oted, bu t on th e m edial side a sm all am ou n t o pu ru len t
f u id w as ou n d arou n d th e n on u n ion zon e. Th ere ore, it
w as qu ite clear th at an in ected n on u n ion w as presen t in
com bin ation w ith a large avascu lar bon e ragm en t. At th is
tim e, th e decision w as m ade to aggressively debride th e
avascu lar bon e, w h ich con sisted o a large area o th e distal
tibia. Con siderin g th e large size o th e bon y de ect, th e
(10 cm in len gth ) an d to recon stru ct th is u sin g a segm en tal
tran sport ( Fig 15 .4 -9c e ). Be ore doin g th is, th e broken plate
on th e bu la (on e-th ird tu bu lar plate) w as replaced by a
n ew (stron ger) lockin g com pression plate (LCP) 3.5, an d an
an kle bridgin g extern al xator w as applied. Th e le t distal
an terolateral avascu lar ragm en t (in volved a sm all part o
th e articu lar su r ace o th e an kle) w as retain ed an d revised
w ith th ree n ew 3.5 m m cortical lag screw s ( Fig 15.4 -9 c ). Th e
de ect zon e w as clean ed by jet lavage u sin g 5 L o lactated
Rin gers solu tion . Both w ou n ds w ere closed over a su ction
drain ( Fig 15 .4 -9 f g ). No dead space ller w as in serted; an
early segm en tal tran sport w as plan n ed or som e days later.

d f

e g
Fig 15.4-9 d g First re vision surge ry afte r plate bre akage , 3 .5 m onths afte r initial injury (cont).
d Aspe ct from poste rom e dial at the le ve l of the distal diaphysis ( proxim al e nd of the se gm e ntal re se ction).
e Re m ove d avascular bone pie ce s.
f g End of surge ry de m onstrating the ankle -bridging e xte rnal xator: late ral aspe ct ( f ) and m e dial aspe ct ( g ).

301
 Se ct io n 3Case s
15.4
Infe cte d
tibial
delaye d
union
with
broke n
im plants
6 Po s t o p e ra t ive m a n a ge m e n t
Broad-spectru m in traven ou s an tibiotic treatm en t w ith
coam oxicillin 2.2 g th ree tim es per day an d gen tam icin 300
m g per day w as started in traoperatively im m ediately a ter
debridem en t an d per orm an ce o tissu e biopsies or m icro-
biological cu ltu res. Th e patien t w as n ot m obilized, x-rays
sh ow ed th e large segm en tal de ect w ith th e tw o su ction
drain s in side ( Fig 15 .4 -10 ). Tw o days later, a secon d-look
operation w ith reopen in g o all w ou n ds, repeat jet lavage,
an d biopsies or cu ltu res w ith w ou n d closu re w as per orm ed.
Th e de n itive resu lts o th e in itial biopsies revealed pen i-
cillin -resistan t bu t oth erw ise sen sitive Staphylococcus epider-
midis an d Staphylococcus hominis, w h ich w ere treated w ith
coam oxicillin , 3 x 2.2 g daily in traven ou sly or 14 days, an d
a b
15.4-10 a b X-rays afte r rst re vision
surge ry de m onstrating the 10 cm
se gm e ntal de fe ct and the re xe d bula
( locking com pre ssion plate 3 .5) and tibia
(e xte rnal xator) in corre ct alignm e nt.
a AP vie w.
b Late ral vie w.
302
later clin dam ycin 3 x 600 m g daily by m ou th or 5 m on th s
u n til th e su rgical treatm en t w as n ish ed. Th e CRP level
rem ain ed n orm al (< 5.0 m g/ L) du rin g th e en tire treatm en t
period. Th e biopsies taken at th e secon d-look operation
w ere cu ltu re n egative. On e w eek a ter th e secon d-look
operation , all th e w ou n ds appeared h ealth y an d n o sign s o
in ection existed ( Fig 15.4 -11 ). Segm en tal tran sport u sin g an
an terom edially placed m on olateral tran sport extern al xator
w as applied ( Fig 15 .4 -12 ). Th e corticotom y w as placed prox-
im ally in th e diaph yseal part o th e tibia w h ich w as n ot
in volved in th e in itial trau m a an d su rgery. On e w eek a ter
corticotom y tran sport o th e segm en t w as started w ith 1 m m
per day u sin g ou r 0.25 m m steps every 6 h ou rs. Th e patien t
w as ollow ed w ith x-rays every 23 w eeks ( Fig 15 .4 -13 ) u n -
til th e dockin g site w as reach ed 100 days later ( Fig 15 .4-14 ).
b
15.4-11a b Clinical aspe ct of the le g 9 days afte r rst re vision
and 7 days afte r se cond-look surge ry.
a Late ral aspe ct.
b Me dial aspe ct.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Christoph Somme r

a b a b a b
15.4-12a b Situation afte r application of the unilate ral 15.4-13a b X-rays 1 we e k afte r the 15 .4 -14 a b X-rays afte r
transport xator ( proxim al to distal) de m onstrating corre ct transport had starte d 10 0 days of transport tim e
ove rall alignm e nt ( le ngth, axis, rotation) with a highly a AP vie w. (1 mm / day, in four ste ps of
m otivate d patie nt. b Late ral vie w. 0 .2 5 m m e ach).
a AP vie w.
b Late ral vie w.

303
 Se ct io n 3Case s
15.4
Infe cte d
tibial
delaye d
union
with
broke n
im plants

7 Re im p la n t a t io n a n d d e fin it ive fixa t io n Alth ou gh th e patien t w as m obilized w ith on ly 1015 kg

On e w eek a ter com pletion o th e segm en tal tran sport,
de n itive in tern al xation w as applied. On on e side, a stron g
an terolateral lockin g com pression plate proxim al lateral
tibia (LCP-PLT) 4.5/ 5.0 w as in serted u sin g a m in im ally in -
vasive plate osteosyn th esis (MIPO) tech n iqu e or th e prox-
im al diaph yseal part to stabilize th e n ew ly gen erated bon e
in th e distraction site in a bridgin g con stru ct. Th e dockin g
site w as sim ilarly xed u sin g an LCP distal m edial tibial plate
3.5 via a MIPO tech n iqu e in a com pression m ode u sin g th e
tran sport xator to m axim ize th e com pression at th e dockin g
site. A sm all, in terposed bon y ragm en t rom th e origin al
ractu re u n ortu n ately h in dered th e desired broad con tact
o th e tw o h orizon tal bon e en ds ( Fig 15 .4-15 ).
partial w eigh t bearin g, 6 w eeks later th e LCP-PLT w as ou n d
to be ben t in 1015 o varu s, m ost likely cau sed by on e
u n in ten ded u lly loaded step w h ich created a sin gle overload
even t or th is stron g plate (patien ts w eigh t: 125 kg) ( Fig
15.4-16 ). Th is m alalign m en t w as n ot tolerable an d it h ad to
be corrected by application o a u rth er plate m edially (LCP
4.5 n arrow ), w h ich w as again in serted u sin g a MIPO tech -
n iqu e a ter ben din g th e lateral plate back in to correct align -
m en t u sin g m an u al orce w ith a m edially applied em oral
distractor ( Fig 15 .4 -17 ).

a b
15.4-15a b X-rays afte r change from
transport e xte rnal xator to inte rnal
stabilization: locking com pre ssion plate
proxim al late ral tibia 4 .5/ 5 .0 ante rolate ral for
the distracte d part and locking com pre ssion
plate 3 .5 distal m e dial tibial plate in
com pre ssion plate te chnique for the distal
docking site , both inse rte d using a m inimally
invasive plate oste osynthe sis te chnique .
a AP vie w.
b Late ral vie w.
a b
15.4-16a b X-rays 6 we e ks afte r inte rnal
xation show a be nt locking com pre ssion
plate proxim al late ral tibia, which m ust have
be e n cause d by one single (or m ultiple)
ove rload(s) by the patie nt standing with full
we ight on this le g.
a AP vie w de m onstrating a varus
de form ity of 15.
b Late ral vie w.
c
15.4-17a c Re vision of a be nt plate .
a Be nding back of the plate ( in situ) by
m anual force .
b In com bination with the large distractor
on the m e dial side .
c Applying a se cond (ante ro) m e dial
plate ( locking com pre ssion plate 4 .5
narrow) using m inim ally invasive plate
oste osynthe sis te chnique .

304 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Christoph Somme r

8 Ou t co m e At 1-year ollow -u p a ter th e in itial in ju ry (an d 3 m on th s

A ter th is last operation , correct align m en t was docu m en ted
on x-rays ( Fig 15.4-18 ). Fu rth er h ealin g w as u n even t u l w ith
tim ely m in eralization o th e n ew ly gen erated bon e at th e
distraction site an d prim arily en dosteal bon e h ealin g at th e
dockin g site 6 w eeks later ( Fig 15 .4 -19 ). Th e an tibiotics w ere
discon tin u ed 6 w eeks a ter th e last su rgery.
a ter th e last operation ), th e patien t w as able to w alk w ith -
ou t cru tch es bu t w as still lim pin g du e to a m oderate pes
equ in u s cau sed by Ach illes ten don sh orten in g ( Fig 15.4-20 ).
Clin ically th e in ection seem ed to be cu red, th e w ou n ds all
closed an d ben ign in appearan ce. On x-rays ( Fig 15 .4 -21 ), th e
distracted diaph yseal segm en t o th e tibia sh ow ed an in creas-
in g m in eralization an d rem odelin g, an d th e bu la w as
u lly u n ited. Th e distal dockin g site w as still n ot com pletely
bridged bu t u rth er h ealin g w as expected.

15.4-18a b X-rays afte r

a b
be nding the plate back and
adding a furthe r m e dial
plate de m onstrating corre ct
alignm e nt as in
Fig 15.4-15a .
a AP vie w.
b Late ral vie w.
a b
15.4-20a b One -ye ar follow-up afte r injury
(3 m onths afte r last surge ry).
a Clinical aspe ct of the still highly m otivate d patie nt.
b Dry and fully he ale d, but broad scars with re m aining
m ode rate soft-tissue swe lling at the lowe r le g and ankle .

15.4-21a b One -ye ar

a b
15.4-19 a b X-rays
6 we e ks late r de m onstrate
incre asing m ine ralization of
the distracte d diaphyse al
se gm e nt but only m inim al
he aling at the distal docking
site .
a AP vie w.
b Late ral vie w.
(3 m onths afte r last surge ry)
a b
follow-up afte r injury
de m onstrate s ongoing and
incre asing m ine ralization of
the distracte d se gm e nt, but
still lim ite d (and que stionable)
e ndoste al he aling at the
docking site .
a AP vie w.
b Late ral vie w.

305
 Se ct io n 3Case s
15.4
Infe cte d
tibial
delaye d
union
with
broke n
im plants

Tw o m on th s later th e patien t retu rn ed w ith in creased pain
an d local ten dern ess at th e dockin g site. Revision su rgery
revealed an atroph ic n on u n ion w ith a sequ estru m an d som e
su rrou n din g f u id su spiciou s or low -grade in ection . Th e
distal m edial plate w as rem oved, th e n on u n ion excised an d
clean ed w ith jet lavage. Biopsies w ere taken or cu ltu res
an d broad-spectru m in traven ou s an tibiotics (coam oxicillin
an d gen tam icin ) w ere started. An extern al xator w as ap-
plied. Two days later a secon d look revealed m acroscopically
clean an d vital tissu es ( Fig 15 .4 -22 ). Th e bon e de ect w as
replaced by gen tam icin polym eth ylm eth acrylate (Masqu elet
tech n iqu e). Th e m icrobiological cu ltu res revealed a resistan t
S epidermidis, w h ich w as treated w ith lon g-term in traven ou s
an tibiotics (van com ycin 2 x 1.5 g daily). Th e n ext operative
step w as per orm ed 6 w eeks later: rem oval o th e cem en t
spacer, de ect llin g w ith tw o au togen ou s tricorticocan cel-
lou s bon e blocks an d addition al can cellou s bon e gra tin g
(iliac crest), an d restabilization o th e tibia w ith a distal
m edial tibial lockin g plate 3.5 ( Fig 15 .4 -23 , Fig 15 .4 -24 ). Th e
last m icrobiological cu ltu res taken w ere n egative an d th e
lon g-term an tibiotic treatm en t (in traven ou s van com ycin )
w as con tin u in g at th e tim e o w ritin g. Fu rth er bon e h ealin g
u n der th is treatm en t con tin u es to im prove. Th e CRP level
retu rn ed to n orm al a ter th e last operation , an d clin ically
th e so t-tissu e situ ation is calm . Th e m ost recen t x-rays, 8
m on th s a ter th e last su rgery, sh ow ed slow bu t progressive
bon e h ealin g, w ith rem odelin g an d in tact im plan ts w ith ou t
loosen in g or bon e resorption arou n d th e screw s ( Fig 15.4-25 ).
Th e patien t is w alkin g pain - ree w ith ou t cru tch es su ggestin g
a stable (at least partially) h ealed bon e situ ation .

15.4-22 Intraope rative situation afte r a b

re vision (se cond look) 5 m onths afte r
the last ope ration, due to a clinically
re activate d infe ction at the docking site .
The bone de fe ct is m acroscopically cle an
and shows vital borde rs. At that tim e ,
the de fe ct was lle d with ge ntam icin
polym e thylm e thacrylate and the wound
close d (Masque le t te chnique). d

c
15 .4 -23 a d Ope rative picture s 6 we e ks late r.
a Cle an, dry situation.
b Re m oval of the ce m e nt space r.
c De fe ct lle d with autoge nous tricorticocance llous bone blocks ( iliac cre st).
d Re stabilization of the tibia with an LCP distal m e dial tibial plate 3 .5 , and furthe r
cance llous bone grafting adde d ante riorly and poste riorly to the plate .

306 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Christoph Somme r
a b
15.4-24a b X-rays afte r the last ope ration
show the bone blocks fully lling the de fe ct
at the form e r docking site .
a AP vie w.
b Late ral vie w.
a b c d
15.4-25a d X-rays 8 m onths afte r the last ope ration (2 ye ars afte r the initial injury)
de m onstrate a nice ly and ne arly fully re m ine ralize d form e r distracte d se gm e nt at the m idshaft
and a slow but progre ssive he aling of the distal docking site with bridging callus poste riorly
and late rally. The im plants are all intact; all scre ws are stable in the bone with intact inte rface s
to the surrounding bone .
a AP vie w (total).
b Late ral vie w (total).
c AP vie w (de tail distally).
d Late ral vie w (de tail distally).
307
 Se ct io n 3Case s
15.4
Infe cte d
tibial
delaye d
union
with
broke n
im plants
9 Pit fa lls
9 .1 Dia gn o s is a n d d e cis io n m a k in g
It m ay be di cu lt to diagn ose a low -grade in ection in
th e settin g o delayed u n ion an d/ or im plan t ailu re
a ter ractu re treatm en t. Tissu e biopsies or cu ltu res are
im portan t in th ese cases.
Th e presen ce o devitalized bon e in cases o (low -grade)
in ected bon e can h arbor on goin g ch ron ic bon e
in ection . In traoperative ju dgm en t o vitality o th e
bon e is im portan t, an d m ay lead to u n der- or overesti-
m ation o th e am ou n t o resection n eeded even by an
experien ced su rgeon . Th ere are n o preoperative
im agin g procedu res available to localize an d qu an ti y
th e devitalized bon e in a precise w ay.
Large segm en tal bon e debridem en t an d recon stru ction
w ith segm en tal tran sport can be risky in cases o poor
patien t com plian ce. Th e decision or th is treatm en t
option m u st be m ade togeth er w ith th e patien t (an d
th e relatives).
9 .2 Su rgica l a p p ro a ch
Th e an terolateral exten ded approach to th e distal tibia can
en dan ger th e su per cial an d deep peron eal n erve an d th e
an terior tibial artery an d vein .
9 .3 Im p la n t re m o va l
In case o im plan t ailu re an d in ection , all th e im plan ts
m u st be rem oved. Broken screw s can be di cu lt to extract.
9 .4 Te m p o ra r y fixa t io n
Extern al xation is easy to apply in th e distal tibia
bridgin g th e an kle join t. Th e u n ilateral ram e m igh t be
in su cien t in large bon e de ect w ith h igh in stability as
in th is case.
Th e Sch an z pin s sh ou ld be ou tside th e in ected zon e.
9 .5 Re im p la n t a t io n
Prem atu re rem oval o extern al xation an d con version to
in tern al xation a ter segm en tal tran sport critically relies
u pon patien t com plian ce. On e sin gle step w ith u ll loadin g
o th e con stru ct can ben d th e plate an d lead to u rth er su r-
gery. It m ay be better to eith er leave th e extern al xator in
place lon ger or to stabilize a lon g-distracted segm en t w ith
a dou ble-plate xation or an in tram edu llary n ail.
308
9 .6 Fa ilu re o f t h e ra p y
In cases o critical so t-tissu e en velope arou n d th e location
o th e corticotom y or oth er risk actors leadin g to an im paired
vitality o th is region , th ese m igh t en dan ger th e n orm al
evolu tion an d m atu rin g o th e n ew bon e orm ation at th e
distraction site.
10 Pe a rls
10 .1 De cis io n m a k in g
Segm en tal tran sport can be an excellen t, sa e, an d
overall a u se u l tech n iqu e to recon stru ct large segm en tal
bon e de ects in th e tibia, i n o com plication s occu r. Th e
com plian t patien t sh ou ld be edu cated con tin u ou sly
over th e du ration o th e treatm en t.
In m ost cases, segm en tal tran sport leads to a very good
n ew bon e qu ality sim ilar to th e n orm al diaph yseal
bon e.
10 .2 Su rgica l a p p ro a ch
Th e an terolateral exten ded approach to th e distal tibia provides
good access to th e distal tibia an d is easier to per orm com -
pared to th e an terolateral approach . Risk o n eu rovascu lar
dam age is low .
10 .3 Im p la n t re m o va l
Failed plates an d screw s m ay be easier to rem ove com pared
to a ailed (broken ) n ail.
10 .4 Te m p o ra r y fixa t io n
An kle bridgin g extern al xation is easy to apply an d h as a
low m orbidity.
10 .5 De fin it ive re vis io n s e co n d s t a ge
Th e early exch an ge o extern al (tran sport) xator to in tern al
xation is w ell received by th e patien t. He or sh e is n ally
rid o th e h ated extern al device. In sertin g a stron g plate
as in tern al xation (eg, LCP) u su ally provides su cien t
stability even w ith very early su rgery im m ediately a ter
n ish in g th e tran sport.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Ste phen L Kate s

15.5 Acu te ly in fe cte d p roxim a l fe m o ra l fra ctu re

d yn a m ic h ip s cre w
Ste p h e n L Kate s

1 Ca s e d e s crip t io n Medication s in clu de: w ar arin , m eth adon e or pain , oxy-

An 81-year-old m an presen ted w ith an in tertroch an teric
h ip ractu re treated w ith a dyn am ic h ip screw at an oth er
h ospital 3 m on th s prior. He in itially ell rom a stan din g
h eigh t w h ile w alkin g in a casin o. He presen ted w ith in trac-
table righ t h ip pain an d a sacral pressu re sore, w ith exposed
bon e grow in g m eth icillin -resistan t Staphylococcus aureus.
con tin , oxycodon e im m ediate release, acetam in oph en , im du r,
lopressor, cym balta, prevacid, in su lin , avan dia, an d aspirin .
Laboratory w orku p revealed: w h ite blood cell cou n t: 10,500
cells/ L, eryth rocyte sedim en tation rate: 66 m m / h , C-reactive
protein : 61 m g/ L.

He h ad previou sly been am bu latory bu t cou ld n ot w alk at 2 In d ica t io n s

th e tim e o presen tation . He h ad rem ain ed in a n u rsin g
h om e sin ce h e w as disch arged rom th e oth er h ospital. He
w as ren dered n on w eigh t bearin g by th e origin al su rgeon
an d developed a postoperative deep vein th rom bosis a ter
th e h ip ractu re.
Past m edical h istory in clu des: h yperten sion , diabetes, coron ary
artery disease w ith sten ts, atrial brillation , m ild dem en tia,
depression , spin al sten osis, esoph ageal ref u x, an d u lcerative
colitis.
Presu m ably, th is m an h ad developed a su rgical-site in ection
ollow in g su rgical repair o th e righ t h ip ractu re ( Fig 15.5-1 ).
He con tin u ally experien ced pain in clu din g n igh ttim e pain .
His system ic in f am m atory m arkers w ere elevated, su pport-
in g a presu m ed diagn osis o in ection . Progressive pain an d
disability prom pted a plan or su rgical exploration o th e
site an d rem oval o th e dyn am ic h ip screw .

a b
Fig 15.5-1a b Oste olysis around the proxim al aspe ct of the dynam ic hip scre w. The re is som e loss of
joint space and incre ase d pe rioste al re action at the trochante ric fracture site .

309
 Se ct io n 3Case s
15.5Acute ly
infe cte d
proximal
femoral
fracture dynamic
hip
scre w

3 Pre o p e ra t ive p la n n in g 5 Su rgica l d e b rid e m e n t

Preoperative plan n in g in clu ded a gen eral m edicin e an d car-
diology ou tpatien t con su ltation to assess th e patien t' s tn ess
or su rgical in terven tion . Both th e cardiologist an d m edical
ph ysician h ad recom m en ded th at su rgery be per orm ed u n -
der gen eral an esth esia. It w as su ggested th at h is w ar arin
be discon tin u ed 5 days prior to su rgery w ith ou t bridgin g
an ticoagu lation . Th is recom m en dation w as based on th e
act th at h e experien ced a sign i can t postoperative bleed at
th e su rgical site ollow in g th e in sertion o th e dyn am ic h ip
screw .
Su rgical debridem en t w as carried ou t a ter rem oval o th e
im plan ts. Th e w all o th e abscess cavity w as excised. Th e
u n derlyin g bon e w as n oted to be covered w ith gran u lation
tissu e. Th e cavity occu pied by th e h ip screw w as cu retted
ree o bio lm an d slim y biological m em bran es. All areas o
devitalized bon e w ere m ech an ically rem oved w ith a ron geu r
an d cu rette. Bon e biopsies w ere sen t to th e path ology lab
or a perm an en t section as w ell as cu ltu re an d sen sitivity.
So t-tissu e cu ltu re w as also sen t to th e laboratory. Fig 15 .5 -2
sh ow s th e path ology resu lts.

Wh en plan n in g th e su rgery, th e appropriate rem oval in stru -
m en ts or th e dyn am ic h ip screw were ordered. Addition ally,
a broken -screw set w as m ade available an d plan s w ere m ade
to obtain path ology, cu ltu re, an d sen sitivity rom th e su rgical
site.
A ter m an agin g th e patien ts h ip in ection , h is sacral pressu re
sore w as debrided back to h ealth y tissu e an d a m oist sterile
n orm al salin e dressin g w as applied.

Position in g w as plan n ed on th e ractu re table w ith avail-

ability o th e im age in ten si er in th e even t th at rem oval o
th e im plan ts proved to be di cu lt. Gen eral an esth esia w as
plan n ed w ith th e atten din g an esth esiologist.

4 Su rgica l a p p ro a ch

Th e su rgical approach w as plan n ed to u se h is old in cision , b

w h ich w as a lon g lateral h ip in cision . Th e in cision itsel w as
w ell h ealed. Th e plan w as to open th e old in cision dow n to
th e ascia lata, split th e ascia lata in lin e w ith its bers an d
retract it, an d th en in cise th e vastu s lateralis m u scle ascia,
splittin g th e m u scle dow n to th e plate. Use o a Ch arn ley
sel -retain in g retractor or exposu re w as plan n ed. Addition -
ally, an gled Weitlan er retractors w ere m ade available or a
exposu re. Fig 15.5-2a b He m atoxylin and e osin staine d se ctions of the
infe cte d right fe moral bone . Acute and chronic oste om ye litis is
de m onstrate d.
Du rin g th e actu al su rgical exposu re, a large abscess w as
en cou n tered, w h ich w as described as th ick cream y pu s.
Cu ltu re an d sen sitivity w as taken o th is liqu id an d o tissu e
su rrou n din g th e im plan ts.

310 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Ste phen L Kate s
6 Im p la n t re m o va l
Im plan t rem oval w as readily carried ou t by rem ovin g all
th e 4.5 m m screw s an d th e plate. Th e plate im plan t w as
ou n d to be som ew h at loosen ed an d w as readily rem oved
by pu llin g it o th e slidin g h ip screw . Th e slidin g h ip screw
w as rem oved w ith th e w ren ch provided by th e m an u ac-
tu rer. No broken im plan ts w ere en cou n tered an d th e im plan t
w as easily explan ted. Fig 15 .5 -3 dem on strates th e im plan t
rem oval an d con dition o th e bon e.
7 Te m p o ra r y fixa t io n
In th is case, it w as decided n ot to place an y addition al
im plan ts in th e bon e or large abscess cavity. A decision w as
m ade to aw ait u rth er laboratory an d cu ltu re in orm ation .
b
Fig 15.5-3 a b Ante roposte rior ( a ) and tube late ral ( b ) right hip
x-rays de m onstrate the re m oval of the im plants and place m e nt of a
suction drain.
8 Po s t o p e ra t ive m a n a ge m e n t
Th e patien t w as allow ed to bear w eigh t as tolerated on th e
righ t h ip. Un ortu n ately, h e h ad persisten t pain th at did n ot
resolve a ter h is w ou n d h ad h ealed. His cu ltu res grew Pep-
tostreptococcus an d Staphylococcus epidermidis sen sitive to van -
com ycin . A con su ltation w as requ ested rom th e in ectiou s
diseases service. He w as started on in traven ou s van com ycin .
He w as also treated w ith im ipen em to cover previou sly
cu ltu red Peptostreptococcus. His postoperative cou rse w as
m arked by persisten t pain w ith w eigh t bearin g th at w as in
th e h ip area rath er th an th e in cision al area.
Du e to h is persisten t pain an d di cu lty w ith w eigh t bearin g,
it w as decided to reoperate an d per orm a Girdleston e pro-
cedu re ( Fig 15.5-4 ). Th e Girdleston e procedu re w as carried
ou t by exten din g h is lateral in cision in to a posterior lateral
exposu re o th e h ip. Th e bon e w as n oted to be so t w ith
sign i can t ch an ges con sisten t w ith ch ron ic osteom yelitis o
th e proxim al em u r. Th e acetabu lu m w as cu retted ree o
in f am ed m em bran es an d th e en tire h ead an d n eck o th e
em u r w as resected. His w ou n d w as closed over a su ction
drain . No addition al pu ru len t m aterial w as n oted at th e tim e
o su rgery, bu t ch ron ic gran u lation tissu e w as presen t. His
postoperative bon e cu ltu res again grew Peptostreptococcus.
Fig 15 .5 -4 Postope rative x-ray
showing rem oval of the fe m oral
he ad and ne ck and subse que nt
de bride m e ntthe Girdle stone
proce dure .
311
 Se ct io n 3Case s
15.5Acute ly
infe cte d
proximal
femoral
fracture dynamic
hip
scre w
9 Re im p la n t a t io n
Th e patien ts con dition w as discu ssed in detail w ith h is
dau gh ter an d th e patien t as w ell as h is prim ary care doctor.
A decision w as m ade n ot to attem pt to im plan t a total h ip
replacem en t based on h is extrem ely di cu lt postoperative
cou rse a ter th e h ip ractu re su rgery. He w as perm itted to
bear w eigh t as tolerated on h is Girdleston e situ ation .
10 Ou t co m e
X-rays 5 years postoperatively are sh ow n in Fig 15 .5 -5 . At
th e presen t tim e, a 9-year ollow -u p is available, dem on -
stratin g th e patien ts ability to am bu late w ith ou t di cu lty
on h is Girdleston e situ ation . He m ostly w alks w ith a walker
ram e an d u ses a 3 cm sh oe li t in h is righ t sh oe. He h as
experien ced n o recu rren ce o in ectiou s sym ptom s an d is
gen erally pleased w ith h is ou tcom e. He is essen tially pain
ree. He still resides in a residen tial h om e w ith n u rsin g
assistan ce.
a Im plan t rem oval: h ave th e correct im plan t-speci c
b con su ltan t.
Fig 15.5-5 a b Ante roposte rior ( a ) and tube
late ral ( b ) x-ray vie ws show the long-te rm re sult
of a Girdle stone proce dure of the right hip.
312
11 Pit fa lls
Diagn osis an d decision m akin g: a pain u l h ip a ter
dyn am ic h ip screw su rgery sh ou ld prom pt con cern or
in ection an d trigger a w orku p or in ection .
Su rgical approach : in ected tissu e is typically sti er an d
m ore di cu lt to m obilize.
Im plan t rem oval: it is im portan t to h ave th e correct
in stru m en t set available to rem ove th e lag screw . A
broken -screw rem oval set sh ou ld be available in th e
even t th at a screw h as broken .
Tem porary xation : th is m ay be di cu lt to ach ieve,
especially in elderly patien ts
Reh abilitation : w eigh t bearin g as tolerated is im portan t
to preven t th e sequ elae o im m obility. Man y older
adu lts w ill h ave di cu lty m obilizin g a ter im plan t
rem oval u n less th e ractu re h as already u n ited.
Reim plan tation : depen din g on th e ch ron icity,
de n itive xation or replacem en t m ay be option s.
Resection arth roplasty is th e oth er reason able option
or debilitated patien ts.
Failu re o th erapy: ailu re o th erapy m ay resu lt rom
ailu re to con trol th e in ection . Rem oval o all
devitalized bon e an d im plan ts are essen tial to h elp
con trol th e in ection . Mu ltiple su rgeries sh ou ld be
avoided in elderly patien ts i possible. Rein ection a ter
revision su rgery sh ou ld prom pt con cern or retain ed
n ecrotic bon e.
12 Pe a rls
Decision m akin g: in terven e early w h en in ection is
diagn osed. Requ est an in ectiou s diseases con su ltation
to determ in e th e best dru g th erapy.
Su rgical approach : u se th e prior in cision an d exten d it
as n eeded.
rem oval set available.
Tem porary xation : an an tibiotic n ail or an tibiotic-
coated tem porary h ip replacem en t are tw o reason able
option s or tem porary xation in th ese cases.
De n itive revision secon d stage: early revision sh ou ld
be plan n ed w h en m edically stable an d th e in ection
h as been con trolled.
An tibiotic m an agem en t: u se bacteriocidal an tibiotics i
possible w ith th e h elp o an in ectiou s diseases
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Michael J Ze gg, Christian Kamme rlander
15.6 Acu te ly in fe cte d p roxim a l fe m o ra l fra ctu re
p ro xim a l fe m o ra l n a il
Michae l J Ze gg, Christian Kam m e rlan d e r
1 Ca s e d e s crip t io n
In early Jan u ary 2011, a 33-year-old patien t presen ted to
th e au th ors departm en t w ith a pertroch an teric ractu re o
th e righ t em u r a ter a all rom 4 m ( Fig 15.6-1 ). Wh ile th e
patien t h ad n ot h ad prior su rgery, m u ltiple alls w ere docu -
m en ted du e to ch ron ic dru g an d alcoh ol abu se. At adm ission ,
th e patien t w as participatin g in a m eth adon e program an d
h ad a Hepatitis C in ection .
Fig 15.6-1 AP x-ray shows a Fig 15 .6 -2 Postope rative AP x-ray with im plante d
pe rtrochante ric fracture of the proximal fe m oral nail.
right fe m ur.
Su rgical treatm en t w ith closed redu ction an d im plan tation
o a sh ort troch an teric en try n ail w as per orm ed ( Fig 15 .6 -2 ).
Despite th e patien ts n on com plian ce, th e im m ediate post-
su rgical period passed w ith ou t com plication s, an d th e patien t
w as disch arged 8 days postoperatively.
Th e patien t su bsequ en tly ell again 4 w eeks postoperatively
du e to alcoh ol an d dru g in toxication , resu ltin g in a periim -
plan t ractu re an d ractu re o th e im plan t ( Fig 15.6-3 ). Revision
su rgery w as per orm ed at th e begin n in g o Febru ary, 2011.
Fig 15.6-3 X-ray control afte r anothe r fall showing
an im plant fracture through the locking scre w hole .
313
 Se ct io n 3Case s
15.6Acute ly
infe cte d
proximal
femoral
fracture proximal
fe moral
nail

Th e sh ort broken im plan t w as rem oved ( Fig 15 .6 -4 ) an d a
lon g n ail w as im plan ted ( Fig 15 .6 -5 ). Th e im m ediate post-
su rgical cou rse w as w ith ou t com plication s, an d th e patien t
w as disch arged a ter 5 days.
Eigh t days a ter th e secon d disch arge, th e patien t presen ted
to th e ou tpatien t clin ic w ith severe pain an d pron ou n ced
sign s o local in ection at th e righ t h ip. Fu rth erm ore, x-rays
sh owed a cu tou t o th e h elical blade ( Fig 15.6-6 ). A com pu ted
tom ograph ic scan sh ow ed f u id reten tion in th e so t tissu e
at th e previou s operation site ( Fig 15.6 -7 ).
Du e to th e cu tou t o th e blade an d both local (redn ess, pu s
at th e proxim al operation w ou n d) an d system ic in ection
sign s w ith C-reactive protein (CRP) 29.81 m g/ dL an d leu -
kocyte cou n t o 17,400 cells/ L ( Fig 15.6-8 ), revision su rgery
w as in dicated.

Fig 15.6-4 Re m ove d proxim al Fig 15.6-5 AP x-ray afte r Fig 15.6-6 Control x-ray shows Fig 15.6-7 Com pute d
fe m oral nail with m ounte d the se cond ope ration with blade cutout. tom ographic scan shows soft-
urinary cathe te r. im plante d proxim al fe m oral nail, tissue uid re te ntion at the
long. ope rative site .

50

40

30

20

10

0
20.02.2011 06.03.2011 20.03.2011 03.04.2011 17.04.2011 07.05.2011

Fig 15.6-8 Syste m ic infe ction signs. Blue: C-re active prote in; gre e n:
le ukocyte count.

314 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Michael J Ze gg, Christian Kamme rlander
Early su rgical in terven tion w as per orm ed a ter plan n in g.
First, operative revision an d debridem en t o th e so t tissu e
w as per orm ed. Th e patien t w as placed in su pin e position
an d th e approach w as per orm ed th rou gh th e prior in cision s.
Su tu res w ere rem oved an d a large qu an tity o pu s w as ou n d
w ith a su bcu tan eou s con n ection betw een th e existin g prox-
im al an d distal in cision s. A ter exten sive debridem en t, sign s
o in ection w ere also presen t arou n d th e greater troch an ter
at th e en try poin t o th e n ail. Th ere w as a large am ou n t o
pu s ou n d an d evacu ated. A ter am ple lavage, a silver-im -
pregn ated n egative-pressu re w ou n d th erapy dressin g w as
applied. Du rin g th e revision operation m an y tissu e sam ples
w ere collected or m icrobiological assessm en t. A ter takin g
th e tissu e sam ples, paren teral an tibiotic th erapy w ith a
secon d-gen eration ceph alosporin w as started.
On th e n ext day, a u rth er revision w as per orm ed. To
m an age th e pron ou n ced in ection , im plan t rem oval w as
in dicated. Th e patien t w as placed in tru e lateral position to
en able operative exposu re i n eeded. Du rin g rem oval o th e
im plan t, pu s w as also ou n d in side th e bon e. Th ere ore, th e
em oral h ead w as rem oved an d in tram edu llary cu rettage
an d ream in g (11.5 m m diam eter) were per orm ed ( Fig 15.6-9 ).
Fu rth er tissu e sam ples w ere collected. In addition , a cem en t
spacer w ith gen tam icin w as orm ed an d im plan ted. Th en
th ree large drain s w ere in serted an d th e operative w ou n d
w as closed ( Fig 15.6-10 ).
Cu ltu re o th e tissu e sam ples revealed an in ection cau sed
by Streptococcus dysgalactiae an d coagu lase-positive Staphylo-
coccus. In accordan ce with th e an tibiogram , an tibiotic th erapy
w as adapted w ith am oxicillin / clavu lan ic acid an d van co-
m ycin .
Th ree days later an oth er septic revision w as per orm ed.
On ce again in tru e lateral position , th e previou s in cision
a b
Fig 15.6-9 a b Intraope rative im age s afte r fe m oral he ad re m oval and intram e dullary
cure ttage .
w as open ed an d resection o n ecrotic tissu e w as con du cted.
Th e cem en t spacer w as also rem oved an d in tram edu llary
ream in g u p to 12 m m was per orm ed. Fu rth erm ore, a lateral
w in dow o th e distal em oral sh a t w as cu t ou t. A ter am ple
debridem en t an d lavage, a n ew cem en t spacer w as in serted.
Th en tw o drain s proxim ally an d on e drain distally, w ere
placed th rou gh th e resected w in dow in side th e em oral sh a t
be ore closin g th e operation w ou n d.
Fu rth er bacteriological tests revealed addition al con tam in a-
tion w ith Escherichia coli. Th ere ore an tibiotic th erapy w as
adapted on ce again w ith piperacillin / tazobactam in stead o
am oxicillin / clavu lan ic acid in con cordan ce w ith th e an ti-
biogram .
Fou r addition al revision operation s w ere per orm ed over
th e n ext 4 w eeks w ith replacem en t o cem en t spacer an d
repeated in tram edu llary in sertion o polym eth ylm eth acry-
late bead ch ain s an d m in ich ain s loaded w ith gen tam icin
su lph ate. Negative-pressu re w ou n d th erapy w as in itiated
to address th e loss o so t-tissu e coverage ollow in g th e above-
m en tion ed repeated resection s o so t tissu e. Du rin g th e last
revision , 6 w eeks a ter readm ission to th e au th ors clin ic,
th e an tibiotic bead ch ain s w ere rem oved, an oth er cem en t
spacer w as in serted, an d th e operation w ou n d closed.
Du e to u rth er bacteriological resu lts an d repeatedly elevated
CRP an d leu kocyte cou n t, an tibiotic th erapy w as adapted
w ith paren teral adm in istration o im ipen em com bin ed w ith
f u con azole.
A ter n early 10 w eeks w ith n o u rth er local or system ic
in ection sign s presen t ( Fig 15.6-8 ), th e patien t w as disch arged
on ce again . Fu rth er oral an tibiotic th erapy w ith f u con azole
w as prescribed an d sh ort-term ollow -u p at th e ou tpatien t
clin ic w as sch edu led.
Fig 15 .6-10 X-ray control afte r
im plante d ce m e nt space r.
315
 Se ct io n 3Case s
15.6Acute ly
infe cte d
proximal
femoral
fracture proximal
fe moral
nail
On e w eek a ter disch arge th e patien t reappeared at th e ou t-
patien t clin ic becau se o pain at th e righ t h ip. X-rays sh ow ed
a broken cem en t spacer ( Fig 15.6-11 ). Blood sam ples sh ow ed
alcoh ol an d dru g in toxication yet n o system ic in crease o
in ection sign s. Also n o local in ection sign s arou n d th e
operation w ou n d w ere presen t.
A ter th orou gh discu ssion , an d con siderin g th e previou s
exten sive in ection , revision operation s, an d n on com plian ce
o th e patien t du e to ch ron ic dru g an d alcoh ol abu se, n o
u rth er revision w as plan n ed. Mobilization w as possible
w ith cru tch es an d also th e pain lessen ed an d so th e patien t
w as disch arged a ter 5 days.
Am bu latory ollow -u p visits sh ow ed a prom isin g cou rse
w ith n o sign s o in ection recu rren ce. Th ere ore revision
su rgery w ith rem oval o th e cem en t spacer an d im plan tation
o an arth roplasty w as con sidered. Th e patien t passed aw ay
du e to dru g in toxication 5 m on th s a ter disch arge.
Fig 15.6-11 AP x-ray with broke n
ce m e nt space r.
316
2 In d ica t io n s
Local in ection sign s: pain , sw ellin g, redden in g, h ealin g
distu rban ce o previou s operation w ou n d, pu s
System ic in ection sign s: ever, h igh blood-level CRP,
elevated leu kocyte cou n t, in terleu kin -6, h igh eryth ro-
cyte sedim en tation rate
X-ray: loosen in g, m ovem en t o im plan t
3 Pre o p e ra t ive p la n n in g
Blood sam ples, local cu ltu re
X-rays
Com pu ted tom ograph ic scan or u rth er plan n in g:
m agn itu de o revision
Im plan t rem oval set, cu ltu re kits, an d con tain ers or
tissu e sam ples or bacteriological testin g
4 Su rgica l a p p ro a ch
Reu se o th e previou s in cision s an d exten sion i requ ired.
5 Su rgica l d e b rid e m e n t
Radical debridem en t is n ecessary w ith rem oval o pu s,
resection o in ected or n ecrotic so t tissu e an d o
in ected or n ecrotic bon e u n til on ly h ealth y so t tissu e
or bleedin g bon e is le t.
Ream in g in tram edu llary can al or rem oval o n ecrotic
an d in ected bon e.
At least ve di eren t tissu e sam ples sh ou ld be collected
or u rth er bacteriological testin g.
Drain s sh ou ld be in serted to preven t f u id reten tion .
I th e radical debridem en t does n ot perm it prim ary
closu re o th e su rgical w ou n d, n egative-pressu re
w ou n d th erapy sh ou ld be con du cted.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Michael J Ze gg, Christian Kamme rlander
6 Im p la n t re m o va l
Im plan t rem oval is u su ally requ ired.
With th e rem oval set an in tram edu llary n ail is straigh t-
orw ard to rem ove.
7 Te m p o ra r y fixa t io n
Cem en t spacer w ith correct diam eter.
An tibiotic bead ch ain s.
8 Po s t o p e ra t ive m a n a ge m e n t
A ter rst so t-tissu e sam ples are gath ered or bacterio-
logical testin g, paren teral an tibiotic th erapy sh ou ld be
started.
Adaptation o an tibiotic th erapy du e to th e an tibiogram
is essen tial.
Fu rth er operative revision s sh ou ld be plan n ed depen d-
in g on local an d system ic in ection sign s, an d u rth er
debridem en t cou ld be n ecessary.
Mobilization is en cou raged: partial w eigh t bearin g w ith
cru tch es du e to th e cem en t spacer.
A ter n o system ic or local in ection sign s a ter 6
m on th s (or even earlier), rem oval o th e spacer an d an
arth roplasty m ay be per orm ed.
9 Ou t co m e
A poor ou tcom e resu lted du e to n on com plian ce; dru g an d
alcoh ol abu se.
10 Pit fa lls
In su cien t diagn ostics an d plan n in g be ore revision .
On ly open in g o th e previou s in cision s w ith ou t
exposu re o th e w h ole in ected area.
In su cien t debridem en t o so t tissu e.
Not rem ovin g th e im plan t in th e early stages o
revision .
No tem porary stabilization leadin g to u rth er disability
or th e patien t.
Early u ll w eigh t bearin g an d stoppin g o an tibiotic
th erapy.
Too early reim plan tation w ith ou t resolved in ection .
No am bu latory ollow -u p, n on com plian ce.
11 Pe a rls
I an in ection is su spected, blood sam ples, cu ltu res,
x-rays, an d option ally a com pu ted tom ograph ic scan
are n eeded to provide all th e in orm ation n eeded or
decision m akin g.
Previou s in cision s n eed to be reopen ed an d en larged to
en able su cien t assessm en t o th e in ection site an d
radical debridem en t.
Im plan t rem oval is u su ally n ecessary to provide th e
possibility o h ealin g by m ean s o destroyin g a bio lm
extracellu lar polym eric su bstan ce an d to allow in tra-
m edu llary debridem en t.
Im plan t rem oval can be tricky especially i th e im plan t
is broken . Sm all h ooks or even a u rin ary cath eter
( Fig 15.6-4 ) can be h elp u l.
Becau se o rem oval o th e em oral h ead, in th is case a
cem en t spacer w as n eeded; th e appropriate diam eter o
th is spacer is essen tial.
Du rin g reh abilitation , am bu latory ch eck-u ps are
cru cial to iden ti y com plication s as early as possible.
An adequ ate am ou n t o tim e w ith ou t in ection is
n eeded be ore arth roplasty or reim plan tation o
in tram edu llary n ails.
In th is case th e rem oval o th e em oral h ead w as n eces-
sary du e to th e advan ced in ection o th e bon e
alth ou gh preservation o bon e sh ou ld be a priority.
317
 Se ct io n 3Case s
15.6Acute ly
infe cte d
proximal
femoral
fracture proximal
fe moral
nail

318 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Zhao Xie

16 .1 Ch ro n ica lly in fe cte d d is t a l tib ia l fra ctu re

Zh ao Xie

1 Ca s e d e s crip t io n 2 In d ica t io n

A 23-year-old m an w as in volved in a m otor veh icle acciden t
an d su stain ed grade IIIB open distal tibial an d bu lar open
ractu res. He w as tran s erred to th e au th ors in stitu tion 13
m on th s a ter th e in itial in ju ry. Debridem en t an d m u scle
ten don repair w ere per orm ed at th e local h ospital. In ection
developed postoperatively an d debridem en t su rgeries w ere
repeatedly per orm ed with n egative-pressu re wou n d th erapy,
bu t th e in ection w as still n ot u n der con trol.
Non u n ion o a tibial com m in u ted ractu re w ith skin de ect
an d exposed n ecrotic bon e are in dication s or su rgical revi-
sion . Th e su rgical plan is to com pletely rem ove th e n ecrotic
bon e an d so t tissu e, stabilize th e ractu re, an d ach ieve w ou n d
coverage.

On adm ission to th e au th ors in stitu tion , ph ysical exam in ation

dem on strated extern al xation an d exposu re o th e distal
en d o th e tibia w ith active drain age ( Fig 16 .1-1 ).

In itial x-ray an d com pu ted tom ograph ic exam in ation dem -

on strated a com m in u ted n on u n ited ractu re o th e distal
tibia, w ith n ecrotic an d in ected bon e distally ( Fig 16 .1-2 ).

a b
Fig 16 .1-1 Clinical appe arance . Fig 16 .1-2 a b Radiological im age s.
a X-ray.
b Com pute d tom ographic scan.

319
 Se ct io n 3Case s
16 .1Chronically
infe cte d
distal
tibial
fracture

3 Pre o p e ra t ive p la n n in g 5 Su rgica l d e b rid e m e n t

In stru m en ts: Th e extern al ixation w as partially rem oved be ore th e

su rgery. All gran u lation tissu e, sequ estra, an d scar tissu e
Pu lsed irrigator w ere com pletely rem oved du rin g su rgery. Necrotic bon e
Pow er drill w as com pletely rem oved u n til h em orrh agic spots w ere seen .
Ream er Th e m edu llary cavity w as ream ed an d th orou gh ly w ash ed
Osteotom e w ith a pu lsed irrigator, an d th e bon e de ect w as created
Bedside x-ray m ach in e ( Fig 16 .1-4 ). Th e dead space w as th en lled w ith an tibiotic-
Lockin g com pression plate loaded bon e cem en t. Cu ltu res w ere obtain ed du rin g th e
su rgical debridem en t.
Oth er:

Position (su pin e) 6 Im p la n t re m o va l

Tou rn iqu et
Topical an tibiotics (van com ycin 10 g, gen tam icin 0.55 g) No im plan t w as u sed du rin g th is su rgery. Th e prim ary
Bon e cem en t extern al xator w as replaced by a lockin g plate.
An tibiotics w ere selected accordin g to test resu lts taken
rom th e w ou n d sam ple (Staphylococcus haemolyticus)
an d piperacillin / tazobactam adm in istered 30 m in u tes
be ore su rgery

4 Su rgica l a p p ro a ch

Th e su rgical approach is rom th e distal tibia ( Fig 16 .1-3 ).

Necrotic tissu e an d bon e sh ou ld be debrided. Th e in cision
was m ade over th e previou s scar, bu t th e m argin o th e wou n d
h ad to be resected. All isch em ic bon e was elim in ated in clu d-
in g a su spected sequ estru m , as bio lm is u su ally presen t,
resu ltin g in rein ection an d u rth er debridem en t su rgery.

Fig 16 .1-3 Distal tibial surgical approach. Fig 16 .1-4 Bone de fe ct afte r de bride m e nt.

320 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Zhao Xie

7 Te m p o ra r y fixa t io n 8 Po s t o p e ra t ive m a n a ge m e n t

An tibiotic bon e cem en t w as im plan ted in to bon e de ects Micrococcus luteus w as ou n d in th e in traoperative sam ple
( Fig 16 .1-5 ), in cision s w ere closed ( Fig 16 .1-6 ), an d extern al taken du rin g bon e gra t su rgery (w h ile th e patien t w as an -
xation w as rebu ilt. tibiotics) an d ce m en oxim e w as selected. Th e patien t w as
given in traven ou s an tibiotics or 2 w eeks a ter su rgery an d
Tips: en cou raged to per orm u n ction al exercises. Less th an 20 kg
o w eigh t bearin g is acceptable. Fu ll w eigh t bearin g w as
To reach ractu re-en d stabilization , th e plate axis proh ibited u n til eviden ce o callu s orm ation w as visible on
sh ou ld be accordan t w ith th e lon gest axis o th e x-rays.
ractu re en d.
High -speed drillin g sh ou ld be avoided in case o tissu e
th erm al n ecrosis in ju ry.
In tryin g to close th e w ou n d du rin g th e h arden in g o
th e bon e cem en t, add or decrease th e volu m e o bon e
cem en t accordin gly.

Fig 16 .1-5 Antibiotic bone ce m e nt im plantation. Fig 16 .1-6 Incision close d.

321
 Se ct io n 3Case s
16 .1Chronically
infe cte d
distal
tibial
fracture

9 Re im p la n t a t io n

Th ere is n o con sen su s on diagn osis o in ection a ter osteo-

m yelitis [1]. In th e au th ors experien ce, i th ere is n o sign o
clin ical in ection a ter 2 m on th s o recovery, C-reactive
protein an d eryth rocyte sedim en tation rate are n orm al. Th e
bon e gra t su rgery w as per orm ed. First, th e bu la w as xed
w ith a lockin g plate ( Fig 16 .1-7 ), th en th e bon e gra tin g w as
carried ou t. Au togen ou s can cellou s bon e w as h arvested rom
th e iliac crest ( Fig 16 .1-8 ) an d w as placed in th e cavity a ter
th e bon e cem en t w as rem oved ( Fig 16 .1-9 ).

Fig 16 .1-7 The bula was xe d with a locking plate .

a b
Fig 16 .1-9a b X-rays afte r bone grafting.
a AP vie w.
b Late ral vie w.

Fig 16 .1-8 Autoge nous bone grafting.

322 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Zhao Xie

10 Ou t co m e

From th e clin ical appearan ce o th e patien t, th ere is n o sign

o in ection a ter th e su rgery ( Fig 16 .1-10 ). Th e extern al x-
ator w as rem oved 1 year a ter su rgery. Bon e corticalization
w as com pleted ( Fig 16 .1-11 ), an d th e patien t w as able to
u lly bear w eigh t.

Fig 16 .1-10 Postope rative clinical appe arance .

a b
Fig 16 .1-11 a b X-rays 18 m onths postope rative ly.
a AP vie w.
b Late ral vie w.

323
 Se ct io n 3Case s
16 .1Chronically
infe cte d
distal
tibial
fracture

11 Pit fa lls 13 Re fe re n ce

1. Wa lt e r G, Ke m m e re r M, Ka p p le r C, e t a l. Treatm en t algorith m s
Tradition al bacterial cu ltu re leads to h igh alse-n egative or ch ron ic osteom yelitis. Dtsch Arztebl Int. 2012
resu lts th at m igh t a ect th e diagn osis o bon e in ection . Apr;109(14):25726 4.
Th is su rgical approach requ ires a broad excision o so t
tissu e an d, th ere ore, m ay lead to di cu lty o w ou n d
h ealin g. Flap design sh ou ld be plan n ed be ore su rgery 14 Ack n o w le d ge m e n t s
i prim ary w ou n d closu re can n ot be ach ieved.
Reh abilitation exercises sh ou ld be lim ited du e to Th e au th or ackn ow ledges th e con tribu tion s o Pro essor
relatively stable plates. Th e patien t is requ ired to h ave Jian Zh on g Xu an d Dr Wei Li.
good com plian ce an d delayed w eigh t bearin g.
In su cien cy o bon e cortex orm ation , bon e resorption ,
an d re ractu re are th e risks o can cellou s bon e gra tin g.

12 Pe a rls

Th e su rgical approach allow s or good exposu re o th e

bon e in ection site or com plete debridem en t.
Extern al xation u sin g th e lockin g com pression plate is
aesth etic an d con ven ien t or th e patien ts to get
dressed.
Topical an tibiotic adm in istration in h ibits bacterial
grow th in th e dead space. Th e am ou n t an d dosage o
system ic an tibiotics u sage can be redu ced.

324 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Zhao Xie

16 .2 Ch ro n ica lly in fe cte d p ro xim a l tib ia l fra ctu re

Zh ao Xie

1 Ca s e d e s crip t io n 3 Pre o p e ra t ive p la n n in g

A 19-year-old m an h ad a le t tibial plateau ractu re w ith In stru m en ts:

proxim al bu lar ractu re cau sed by a m otor veh icle acciden t.
Be ore h e w as re erred to th e au th ors h ospital, h e w as Pu lsed irrigator
treated w ith in tern al xation an d allogra t. On in itial ex- Pow er drill
am in ation , h e h ad w ou n d drain age w ith pu ru len t exu date Ream er
an d a lateral exposed tibial plate ( Fig 16 .2 -1 , Fig 16 .2 -2 ). Osteotom e
Bedside x-ray m ach in e
Hybrid xator an d lockin g com pression plate (LCP)
2 In d ica t io n
Oth er:
Th e plate exposu re w ith pu ru len t exu date served as an
obviou s in dication or bon e in ection su rgery. Th e ractu re Position
sh ou ld be stabilized, w ou n ds covered, an d in ection ocu s Tou rn iqu et
con trolled w ith su rgery. Topical an tibiotics (van com ycin 10 g, gen tam icin 0.55 g)
Bon e cem en t
An tibiotics w ere selected accordin g to dru g test resu lts
on th e w ou n d sam ple (Escherichia coli an d Acinetobacter
baumanii); th ird-gen eration ceph alosporin ce m en oxim e
is adm in istered 30 m in u tes be ore su rgery

Fig 16 .2-1 Pre ope rative appe arance . Fig 16 .2-2 AP x-ray vie w.

325
 Se ct io n 3Case s
16 .2Chronically
infe cte d
proximal
tibial
fracture

4 Su rgica l a p p ro a ch An y dead tissu e an d scar tissu e are rem oved to en h an ce th e

Th e in cision ollow ed th e previou s scar, bu t th e m argin o
th e w ou n d h ad to be resected ( Fig 16 .2 -3 ).
5 Su rgica l d e b rid e m e n t
All gran u lation tissu e, sequ estra, an d scar tissu e w ere com -
pletely rem oved du rin g su rgery. Su spiciou s n ecrotic bon e
sh ou ld be rem oved u n til h em orrh agic spots are seen [1].
recovery o blood su pply. Th e m edu llary cavity is ream ed
an d w ash ed th orou gh ly w ith pu lsed irrigator. Segm en tal
isch em ic bon e (wh ite, ben eath th e tibial plateau ) was retain ed
a ter th e rst debridem en t ( Fig 16 .2-4 ).Th e dead space w as
th en lled w ith an tibiotic-loaded bon e cem en t (van com ycin
10 g an d gen tam icin 0.55 g). Th e clin ical appearan ce a ter
th e rst debridem en t 3 m on th s later sh ow ed an active sin u s
tract ( Fig 16 .2 -5 ). Th e plan n ed bon e gra tin g w as aborted;
th e patien t u n derw en t an oth er debridem en t an d th e ex-
tern al xator w as replaced ( Fig 16 .2 -6 ).

Fig 16 .2-3 Surgical approach. Fig 16 .2-4 Bone de fe ct afte r rst de bride m e nt.

Fig 16 .2-5 Clinical appe arance 3 m onths afte r rst de bride m e nt. Fig 16 .2-6 Bone de fe ct afte r se cond de bride m e nt. The ne crotic
se gm e nt of bone has now be e n re m ove d. In re trospe ct, it should
have be e n re m ove d during the initial de bride m e nt.

326 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Zhao Xie

6 Im p la n t re m o va l 7 Te m p o ra r y fixa t io n

Th e plate an d screw s w ere com pletely exposed an d th e screw s Fixation o th e bon e in ection site is u su ally extern al. Con -
o th e an terolateral an d in tern al plates were rem oved du rin g siderin g th e com plian ce o th e patien t, an LCP w as u sed or
th e rst debridem en t ( Fig 16 .2 -7 ). th is extern al xation ( Fig 16 .2-8 , Fig 16 .2 -9 ).

Tips:

Th e lockin g plate is m ore com pact com pared w ith th e

h ybrid xator, bu t care u l postoperative m an agem en t
is im portan t.
Su spiciou s n ecrotic bon e sh ou ld be rem oved at in itial
debridem en t to avoid th e n eed or a secon d debridem en t
( Fig 16 .2 -4 , Fig 16 .2 -6 ).

a b
Fig 16 .2-7 Im plants have be e n re m ove d. Fig 16 .2-8a b X-rays afte r de bride m e nt show e xte rnal
xation and the ce m e nt space r.
a AP vie w.
b Late ral vie w.

Fig 16 .2-9 Antibiotic bone -ce m e nt wrappe d bone de fe cts

(Masque le t te chnique) [2].

327
 Se ct io n 3Case s
16 .2Chronically
infe cte d
proximal
tibial
fracture

8 Po s t o p e ra t ive m a n a ge m e n t 10 Ou t co m e

Acinetobacter baumanii w as cu ltu red rom th e in traoperative Th e extern al f xator w as rem oved 1 year a ter su rgery. Bon e
sam ple du rin g bon e gra tin g su rgery an d an tibiotic regim en corticalization was com pleted at th e last ollow-u p ( Fig 16 .2-11 ),
con sistin g o piperacillin / tazobactam w as selected. Th e an d th e patien t w as able to u lly bear w eigh t.
patien t w as given in traven ou s an tibiotics or 2 w eeks a ter
su rgery an d en cou raged to per orm u n ction al exercises.
Less th an 20 kg o w eigh t bearin g w as recom m en ded. Fu ll
w eigh t bearin g w as proh ibited u n til eviden ce o callu s or-
m ation w as visible on x-rays.

9 De fin it ive fixa t io n

Accu rate diagn osis o in ection can be a problem [3]. Th ere

w ere n o clin ical in ection sign s a ter 2 m on th s o recovery;
C-reactive protein an d eryth rocyte sedim en tation rate w ere
n orm al, so th e bon e gra t su rgery was carried ou t ( Fig 16 .2-10 ).
Au togen ou s can cellou s bon e w as h arvested rom th e iliac
crest. At th e patien ts requ est th e extern al plate w as n ot
ch an ged.

a b a b
Fig 16 .2-10 a b Postope rative bone graft x-rays. Fig 16 .2-11a b X-rays take n 18 m onths postope rative ly.
a AP vie w. a AP vie w.
b Late ral vie w. b Late ral vie w.

328 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Zhao Xie

11 Pit fa lls 13 Re fe re n ce s

Tradition al bacterial cu ltu re leads to h igh alse-n egative
resu lts th at m igh t a ect th e diagn osis o bon e in ection .
Th is is o ten th e resu lt o em piric an tibiotic treatm en t.
Cu ltu res sh ou ld be m ade rom deep specim en s obtain ed
w h en th e patien t is n ot receivin g an tibiotics or at least
2 w eeks.
Th is su rgical approach requ ires a broad excision o so t
tissu e an d, th ere ore, m ay lead to di cu lty in w ou n d
h ealin g.
Reh abilitation exercises sh ou ld be lim ited du e to th e
relatively stable plate. Th e patien t is requ ired to h ave
good com plian ce an d delayed w eigh t bearin g.
In su cien cy o bon e cortex orm ation , bon e resorption ,
an d re ractu re are th e risks o can cellou s bon e gra tin g.
1. Te t s w o rt h K, Cie rn y G 3rd . Osteom yelitis debridem en t
tech n iqu es. Clin Orthop Relat Res. 1999 Mar;(360):8796.
2. Ma s q u e le t AC, Be gu e T. Th e con cept o in du ced m em bran e or
recon stru ction o lon g bon e de ects. Orthop Clin North Am. 2010
Jan 41(1):2737.
3. Wa lt e r G, Ke m m e re r M, Ka p p le r C, e t a l. Treatm en t algorith m s
or ch ron ic osteom yelitis. Dtsch Arztebl Int. 2012
Apr;109(14):257264.
14 Ack n o w le d ge m e n t s
Th e au th or o th is ch apter ackn ow ledges th e con tribu tion s
o Pro essor Jian Zh on g Xu an d Dr Ke Hu an g.

12 Pe a rls

Th e su rgical approach allow s or good exposu re o th e

bon e in ection site or com plete debridem en t.
Extern al xation o LCP is aesth etically acceptable an d
con ven ien t or patien ts to get dressed.
Topical an tibiotics adm in istration in h ibits bacterial
grow th in th e dead space. Th e am ou n t an d dosage o
system ic an tibiotics u sage can be redu ced.

329
 Se ct io n 3Case s
16 .2Chronically
infe cte d
proximal
tibial
fracture

330 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Chang-Wug Oh

16 .3 Ch ro n ica lly in fe cte d d is t a l fe m o ra l fra ctu re

Ch an g-Wu g Oh

1 Ca s e d e s crip t io n

A 56-year-old m an su stain ed a Gu stilo-An derson com m i-

n u ted type IIIB ractu re o th e righ t distal em u r (33-C2)
du rin g a m otor veh icle acciden t ( Fig 16 .3-1 ). Th e ollow in g
day a th orou gh debridem en t w as per orm ed ollow ed by
in tern al xation w ith plate an d screw s ( Fig 16 .3 -2 ). A deep
in ection developed 4 days postoperatively.

a b c a b c
Fig 16 .3-1 a c A com minute d ope n type IIIB fracture of the right Fig 16 .3-2a c Afte r m e ticulous de bride m e nt of the dirty wound,
distal fe m ur (33 -C2). inte rnal xation was pe rform e d.
a AP x-ray. a AP x-ray.
b Late ral x-ray. b Late ral x-ray.
c Clinical appe arance . c Clinical appe arance .

331
 Se ct io n 3Case s
16 .3Chronically
infe cte d
distal
femoral
fracture
2 In d ica t io n s
Acu te in ection w as stron gly su spected w ith elevated labo-
ratory test resu lts an d th e clin ical n din gs o redn ess an d
w arm th ( Fig 16 .3 -3a ), so w ou n d exploration an d debridem en t
w as deem ed n ecessary ( Fig 16 .3-3b c ).
3 Pre o p e ra t ive p la n n in g
Several debridem en ts w ere per orm ed to ach ieve con trol o
th is deep in ection . Th e im plan t sh ou ld be retain ed u n less
th ere is in ection su rrou n din g it. At th e tim e o debridem en t,
radical resection o all n ecrotic bon e w as per orm ed u n til
viable bon e m argin s w ere visu alized proxim ally an d dis-
tally to th e ractu re site. Sam ples w ere obtain ed or bacte-
rial an d u n gal cu ltu res an d a rozen -section path ological
exam in ation w as con du cted du rin g debridem en t. An y dead
space sh ou ld be lled w ith an tibiotic-loaded cem en t beads
or spacers. In a secon d procedu re, th e bon e de ect can be
m an aged by au togen ou s bon e gra t or bon e tran sport ac-
cordin g to its size.
a b c a
Fig 16 .3-3a c
a On postope rative day 3 , postope rative infe ction was suspe cte d
with the localize d re dne ss and he at.
b c The wound was the n de bride d again and cle ane d.
332
4 Su rgica l a p p ro a ch
Th e lateral parapatellar approach w as u sed. Th is approach
m ay provide a good view o th e articu lar su r ace o th e
distal em u r, w h ich m ay h elp in rem oval o an y rem ain in g
sou rces o in ection . With a lon gitu din al division o th e
qu adriceps ten don an d exten sor m ech an ism , th e patella w as
dislocated m edially. A tou rn iqu et w as u sed to m in im ize
blood loss an d to im prove th e view o th e articu lar su r ace.
5 Su rgica l d e b rid e m e n t
Every 1 or 2 weeks, debridem en t, wou n d irrigation , ch an gin g
o th e an tibiotic m ixed-cem en t spacer (gen tam icin an d rst-
gen eration ceph alosporin ce alozin 1 g), an d n egative-
pressu re w ou n d th erapy w as per orm ed, w h ile th e plate
w as retain ed. Th e organ ism cu ltu red w as Enterobacter aero-
genes. With several repeated debridem en ts o n ecrotic bon e
an d so t tissu e, a 5 cm bon e de ect w as created in th e distal
m etadiaph yseal area. Eigh t w eeks a ter in itial trau m a, th e
w ou n d w as closed w ith ou t eviden ce o in ection (n egative
cu ltu res) ( Fig 16 .3-4 ). Bon e tran sport w as plan n ed or w h en
b c
Fig 16 .3-4a c Afte r se ve ral rounds of wound de bride m e nt and
re se ction of de ad bone , the antibiotic-ce m e nt space r was inse rte d at
the se gm e ntal bone de fe ct of the distal fe m ur.
a AP x-ray.
b Late ral x-ray.
c Clinical appe arance . At 8 we e ks afte r initial injury, the infe ction
was controlle d, with stabilization of infe ctious signs from the
laboratory.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Chang-Wug Oh

th ere w as n o clin ical or laboratory eviden ce o in ection , 6 Bo n e t ra n s p o r t p ro ce d u re

based on th e f n din gs o eryth rocyte sedim en tation rate an d
C-reactive protein in vestigation s. A rozen -section biopsy
o th e so t tissu e taken rom th e de ect sh ou ld also be
per orm ed at th e tim e o th e bon e tran sport procedu re. I
polym orph on u clear leu kocytes are less th an 3 per h igh -
pow er f eld, th e recon stru ctive procedu re (eith er bon e gra t
or bon e tran sport) can be per orm ed w ith m in im al risk o
recu rren t in ection [1, 2].
No in ection w as ou n d arou n d th e lockin g plate so it w as
retain ed; it w as plan n ed to u se a bon e tran sport w ith ex-
tern al f xator an d a lockin g plate (BTLP) or a large-bon e
de ect o th e distal em u r [1 , 3 ]. Th is tech n iqu e com prises
th ree stages, tw o operation s, an d th e in terven in g tran sport
period. Fig 16 .3-5 sh ow s diagram m atically th e plan n ed pro-
cedu re.

Corticotomy

a b c d e

Fig 16 .3-5a g Diagram of the planne d inte rnal bone transport.

a The distal fe m oral fracture with se gm e ntal bone de fe ct.
b The plate is xe d with cluste rs of scre ws at the proxim al and distal parts.
c The Schanz pins of the e xte rnal xator are xe d ante riorly. The corticotomy is pe rform e d
be twe e n the proximal scre ws of the plate and distal pins of the e xte rnal xator.
d The n, the le ngthe ning fram e is attache d and the gradual distraction will be pe rform e d
at 1 m m pe r day.
e The m iddle (transporte d) se gm e nt will dock to the distal se gm e nt. At this tim e , the
scre ws will be xe d at the transporte d se gm e nt with the bone graft at the docking site .
f The n, the e xte rnal xator will be re m ove d at the following proce dure .
g The distracte d callus will be harde ne d with the prote ction of the inte rnal xator, which
may he lp the patie nts e arly re habilitation.

f g

333
 Se ct io n 3Case s
16 .3Chronically
infe cte d
distal
femoral
fracture

Th e rst stage in volves plate xation , extern al xation , an d
osteotom y. In th is case, th e screw location at th e proxim al
segm en t w as ch an ged w h ile th e screw s at th e distal con dy-
lar segm en t w ere n ot rem oved. Th ree screw s w ere xed at
th e u pperm ost area. A u n ilateral extern al xator was ch osen
in th is case. It w as applied at th e proxim al segm en t, in w h ich
th ree Sch an z pin s w ere xed above to th e proxim al en d o
th e plate an d tw o pin s w ere xed below to th e proxim al
screws o th e plate. All Sch an z pin s were in serted an teriorly,
su ch th at th ey did n ot con tact th e lockin g plate or its screw s.
Fin ally, a percu tan eou s osteotom y w as per orm ed u sin g
m u ltiple drill h oles an d an osteotom e ( Fig 16 .3 -6 ).
Th e secon d stage con cern s bon e tran sport. Distraction started
at a rate o 1 m m / day (0.25 m m per tim e, ou r tim es per
day) a ter 10 days o laten cy, to perm it regen eration o th e
periosteal blood su pply at th e corticotom y sites. Tran sport
w as per orm ed in an an tegrade direction ( rom proxim al to
distal). AP an d lateral x-rays were taken w eekly or biw eekly
to assess th e orm ation o callu s.
Th e th ird stage w as con du cted a ter th e m iddle segm en t
approach ed its dockin g position , arou n d 3 m on th s a ter th e
in dex procedu re ( Fig 16 .3-7 ). Th is stage con sisted o screw
xation at th e tran sported segm en t, an d rem oval o th e

a b a b
Fig 16 .3-7a b X-rays showing the m iddle se gm e nt
approaching the distal se gm e nt.
a AP vie w.
b Late ral vie w.

c d
Fig 16 .3-6a d Postope rative x-rays and clinical appe arance .
a b Unilate ral e xte rnal xator xe d ante riorly and locking plate
xe d late rally. Note the oste otomy site .
cd Clinical appe arance afte r the ope ration ( bone transport
with locking plate and e xte rnal xator).

334 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Chang-Wug Oh
extern al xator. Screw xation o th e m iddle segm en t w as
per orm ed prior to rem ovin g th e xator. Un der im age in -
ten si er gu idan ce, th e em pty plate h oles on th e m iddle
segm en t are m arked or th e plan n ed screw xation . A ter
m akin g stab in cision s over th e h oles, th ree screw s w ere
placed percu tan eou sly. Th e xator an d its pin s w ere th en
rem oved an d th e w ou n ds created w ere th orou gh ly clean ed.
Th en , au togen ou s bon e gra t was per orm ed with addition al
u se o bon e su bstitu te (calciu m su l ate) at th e dockin g site
( Fig 16 .3 -8 ).
a b c a
Fig 16 .3-8a c X-rays and clinical im age show thre e scre ws xe d on
the m iddle se gm e nt pe rcutane ously. At the sam e tim e , autoge nous
bone graft was pe rform e d with additional use of bone substitute
(calcium sulfate) at the docking site . The n e xte rnal xator and pins
we re re m ove d.
7 Po s t o p e ra t ive m a n a ge m e n t
X-rays w ere taken every 4 w eeks u n til th e callu s w as u lly
con solidated. Mobilization o th e join ts w as en cou raged an d
partial w eigh t bearin g started im m ediately a ter rem oval o
th e xator. Wh en sign s o bon y con solidation w ere observed
in at least th ree cortices on AP an d lateral x-rays, th e patien t
w as allow ed to w alk bearin g u ll w eigh t w ith cru tch es, an d
th en slow ly w ean ed o th e cru tch es as tolerated.
8 Ou t co m e
A ter 15 m on th s, both th e dockin g an d distraction sites w ere
h ealed ( Fig 16 .3 -9 ). Th e righ t leg w as 25 m m sh orter th an
th e le t leg, w ith a sligh t varu s de orm ity. As th e qu adriceps
m u scle was severely dam aged, th e patien t h ad lim ited m otion
o th e kn ee ( Fig 16 .3 -10 ).
b
Fig 16 .3-9a b Afte r 15 m onths both the docking and distraction
site s he ale d une ve ntfully.
a AP vie w.
b Late ral vie w.
Fig 16 .3-10 The patie nt had limite d m otion of the kne e with le ss
than 30 of e xion. This m ay have be e n a re sult of the initially
se ve re ly damage d quadrice ps m uscle .
335
 Se ct io n 3Case s
16 .3Chronically
infe cte d
distal
femoral
fracture

9 Pit fa lls 11 Re fe re n ce s

1. Oh CW, Ap iva t t h a ka ku l T, Oh JK, e t a l. Bon e tran sport w ith an

Th e tim in g o closu re o open ractu re w ou n ds h as been
con troversial. Th e recen t tren d in th e literatu re in dicates
th at m eticu lou s debridem en t by an experien ced su rgeon
ollow ed by prim ary w ou n d closu re is sa e in m an y circu m -
stan ces in clu din g type III open ractu res [4]. How ever, as in
th is case, th ere are several actors con tribu tin g to w ou n d
in ection . Th ese w ere ailu res o om ission su ch as n ot rec-
ogn izin g a ractu re as open m ay cau se th e ractu re to be
treated or debrided less aggressively, w h ich m ay avor in ec-
tion . Alth ou gh th e optim al tim in g or th e treatm en t o open
ractu res rem ain s a m atter o con troversy, tim ely debridem en t
is still avored by m ost su rgeon s. Local actors su ch as bon e
or so t-tissu e loss, vascu lar or n erve in ju ry, or com partm en t
syn drom e m ay all in f u en ce th e poten tial or com plication s.
10 Pe a rls
On e o th e greatest advan tages o BTLP tech n iqu e is th e
early rem oval o th e extern al xator. Alth ou gh distraction
osteogen esis provides a h igh ly satis actory m ean s o recon -
stru ctin g segm en tal tibial de ects, prolon ged u se o an
extern al xator is di cu lt or patien ts an d com plication s,
su ch as pin -track in ection s, pin breakage, pin loosen in g,
an d join t con tractu res are alm ost in evitable [5]. Tri ocal an d
tetra ocal m eth ods o bon e tran sport w ith m u ltiple oste-
otom ies an d tw o or th ree levels o bon e regen eration h ave
been reported to sh orten treatm en t tim es. How ever, th e
con solidation o distraction callu s an d dockin g sites, w h ich
represen t th e lon gest ph ase o th e bon e tran sport tech n iqu e,
are little redu ced w ith an extern al xator as th e m ean s o
stabilization . Bon e tran sport w ith lockin g plate tech n iqu e
n eeds m in im al tim e with extern al xation , wh ich m ay redu ce
related com plication s as seen in th e sim ilar procedu re or
lim b len gth en in g [6].
extern al xator an d a lockin g plate or segm en tal tibial de ects.
Bone Joint J. 2013 Dec;95-B(12):16671672.
2. Ap iva t t h a ka ku l T, Arp o rn ch a ya n o n O. M in im ally in vasive plate
osteosyn th esis (M IPO) com bin ed w ith d istraction osteogen esis
in th e treatm en t o bon e de ects. A n ew tech n iqu e o bon e
tran sport: a report o two cases. Injury. 2002 Ju n ;33(5):460
4 65.
3. Oh CW, So n g HR, Ro h JY, e t a l. Bon e tran sport over an
in tram edu llar y n ail or recon stru ction o lon g bon e de ects in
tibia. Arch Orthop Trauma Surg. 2008 Au g;128(8):801808.
4. Je n k in s o n RJ, Kis s A, Jo h n s o n S, e t a l. Delayed wou n d closu re
in creases deep-in ection rate associated w ith lower-grade open
ractu res: a propen sity-m atch ed coh ort stu dy.
J Bone Joint Surg Am. 2014 Mar 5;96(5):380 386.
5. Pa p a ko s t id is C, Bh a n d a ri M, Gia n n o u d is PV. Distraction
osteogen esis in th e treatm en t o lon g bon e de ects o th e lower
lim bs: e ectiven ess, com plication s an d clin ical resu lts; a
system atic review an d m eta-an alysis. Bone Joint J. 2013
Dec;95-B(12):1673 1680.
6. Oh CW, So n g HR, Kim JW, e t a l. Lim b len gth en in g w ith a
su bm u scu lar lock in g plate. J Bone Joint Surg Br. 2009
Oct;91(10):1394 1399.
7. Ko ca o glu M, Era lp L, Ra s h id HU, e t a l. Recon stru ction o
segm en tal bon e de ects du e to ch ron ic osteom yelitis w ith u se o
an extern al xator an d an in tram edu llary n ail. J Bone Joint
Surg Am. 2006 Oct;88(10):21372145.

Loss o axial align m en t an d distraction callu s ractu res are

n ot u n com m on w h en tran sport is per orm ed u sin g on ly an
extern al xator. Th e addition o a prein serted lockin g plate
protects distraction an d tran sport segm en ts, m in im izin g th e
in ciden ce o m alalign m en t w h en BTLP is per orm ed. It also
protects th e distraction callu s su cien tly w h ile perm ittin g
early m obilization . Th e lockin g plate is also h elp u l w h en
n ailin g is di cu lt in ju xtaarticu lar bon e de ects w ith a sh ort
rem ain in g segm en t [3, 7].

336 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Tak-Wing Lau
16 .4 Ch ro n ica lly in fe cte d h ip h e m ia rth ro p la s t y
Tak-Win g Lau
1 Ca s e d e s crip t io n
An 82-year-old w om an w as adm itted to h ospital ollow in g
a sim ple all on level grou n d resu ltin g in le t h ip pain . Th e
patien t h ad been in good h ealth an d on ly took an an tide-
pressan t. Sh e requ ired a can e or w alkin g be ore th is in ju ry.
a b
Fig 16 .4-1 a b X-rays of the le ft hip show a displace d le ft fe m oral
ne ck fracture .
a AP vie w of the pe lvis shows that the displace d fe m oral ne ck
fracture has shorte ne d.
b Late ral vie w of the le ft hip shows the displace d fracture is in
re trove rsion.
A ter adm ission , sh e w as ou n d to h ave im paired glu cose
in toleran ce. X-rays o h er le t h ip sh ow ed a displaced le t
em oral n eck ractu re ( Fig 16 .4-1 ).
On day 2 a ter adm ission , sh e received a le t Au stin Moore
(AM) h em iarth roplasty u n der spin al an esth esia ( Fig 16 .4 -2 ).
a b
Fig 16 .4-2a b On day 2 afte r adm ission, the patie nt re ce ive d a le ft
Austin Moore he m iarthroplasty unde r spinal ane sthe sia.
a AP vie w.
b Late ral vie w.
337
 Se ct io n 3Case s
16 .4Chronically
infe cte d
hip
hemiarthroplasty

Th e procedu re w as u n even t u l. Sh e w as readm itted to h os-
pital 2 m on th s later w ith a low -grade ever an d in creasin g
le t h ip pain or 1 m on th . Sh e w as able to w alk in depen -
den tly w ith a w alker. Repeated x-rays o th e le t h ip sh ow ed
n o obviou s loosen in g o stem or erosion o th e acetabu lu m
( Fig 16 .4 -3 ).
Laboratory testin g sh owed elevated eryth rocyte sedim en tation
rate (ESR) > 140 m m / h an d C-reactive protein (CRP) > 20
m g/ L. Th e patien t also reported acu te w eigh t loss o 9 kg in
th e precedin g 2 m on th s. In view o th e clin ical situ ation ,
sh e w as re erred or a positron -em ission tom ograph y com -
pu ted tom ograph y (PET-CT) scan to ru le ou t u n derlyin g
m align an cy ( Fig 16 .4 -4 ). Th e PET-CT scan dem on strated an
abscess in th e le t h ip region w ith in volvem en t o th e ace-
tabu lu m an d iliu m as w ell. A h ip join t aspirate w as per orm ed
an d sh ow ed n o grow th . Exploration , debridem en t, an d
revision to a tem porary prosth esis o van com ycin -loaded
acrylic cem en t w ere per orm ed 1 w eek later ( Fig 16 .4 -5 ).
Cu ltu re o th e syn oviu m sh ow ed m eth icillin -sen sitive
Staphylococcus aureus in ection . In traven ou s cloxacillin an d
oral ri am pin w ere given or 1 w eek th en cloxacillin w as
also given orally. How ever, th e patien t developed gastroin -
testin al side e ects a ter 6 w eeks o treatm en t. Cloxacillin
an d ri am pin w ere stopped an d oral clarith rom ycin w as th en
given or an oth er 6 w eeks.

a b
Fig 16 .4-3a b Re pe ate d x-rays of the le ft hip showe d no obvious
loose ning of the ste m or e rosion of the ace tabulum .
a AP vie w shows loss of joint space only.
b Late ral vie w shows the ste m without obvious change s.

a b
Fig 16 .4-4a b In vie w of the clinical situation, the patie nt was re fe rre d for a positron-e m ission tom ography com pute d tom ography (PET-CT)
scan to rule out unde rlying m alignancy.
a PET-CT shows e vide nce of in am m ation absce ss around the ilium .
b PET-CT shows e vide nce of in am m ation absce ss around the im plants.

338 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Tak-Wing Lau

Six m on th s later, th e patien t w as w alkin g w ith a ram e.
Th ere w as persisten t h ip pain bu t it w as im provin g. Th e ESR
an d CRP also im proved sign i can tly. Th e an tibiotic spacer
prosth esis w as th en su ccess u lly revised to a total h ip re-
placem en t ( Fig 16 .4-6 ) w ith ou t rein ection . Eigh teen m on th s
later, th e x-ray sh ow ed em oral stem loosen in g. Alth ou gh
loosen in g du e to ch ron ic in ection w as su spected, serial blood
tests in clu din g ESR an d CRP sh ow ed n o eviden ce o rein -
ection . Hip aspiration sh ow ed n orm al cell cou n t an d
n egative cu ltu re. Th ere ore, a secon d revision su rgery o
th e loosen ed em oral stem w as per orm ed. Ceph azolin w as
u sed as a proph ylactic an tibiotic. No an tibiotics w ere given
a ter th e operation . Th e patien t w as by n ow am bu latory
w ith a ram e w ith m ild h ip pain . Her x-ray an d blood tests
sh ow ed n o loosen in g o th e prosth esis or eviden ce o rein -
ection ( Fig 16 .4 -7 ).

a b
Fig 16 .4-5a b The positron e m ission tom ography-com pute d
tom ography scan de m onstrate d an absce ss in the le ft hip re gion with
involve m e nt of the ace tabulum and ilium as we ll. A hip joint aspirate
was pe rform e d and showe d no growth. Exploration, de bride m e nt,
and re vision to a te m porary prosthe sis of antibiotic-loade d acrylic
ce m e nt we re pe rform e d 1 we e k late r.
a AP pe lvic vie w shows temporary prosthe sis in place.
b AP fe m oral vie w shows the im plant in the fe m ur.
a b
Fig 16 .4-6a b The antibiotic space r prosthe sis was the n
succe ssfully re vise d to a total hip re place m e nt.
a The total hip is se e n in place . A trochante ric oste otom y was
use d and cable s are back in place .
b Late ral vie w of the re vise d prosthe sis in place . A m onoblock
ste m was use d.

a b c d
Fig 16 .4-7a d The fe m oral ste m re quire d a se cond re vision 18 m onths late r be cause of ase ptic loose ning. Blood te sts showe d no e vide nce
of re infe ction.
a AP fe m oral vie w: e xchange with a longe r ste m , supple m e nte d with cable s and allograft struts.
b AP fe mur: the straight long ste m did not fully match the fe m ur bowing. A fe m oral allograft was re quire d distally.
c Late ral vie w proximally shows cable s and allografts.
d Late ral vie w distally shows cable s and allografts.

339
 Se ct io n 3Case s
16 .4Chronically
infe cte d
hip
hemiarthroplasty
2 In d ica t io n s
2 .1 In d ica t io n s fo r s u rgica l t re a t m e n t
A sym ptom atic le t h ip h em iarth roplasty in ection ,
w h ich presen ts w ith in creasin g pain an d system ic
sym ptom s, ie, ever, w eigh t loss.
X-rays m ay sh ow eatu res o im plan t loosen in g an d
rapid bon e loss, acetabu lar erosion , an d periosteal
reaction .
Hip join t aspiration is th e stan dard tech n iqu e or
diagn osis, w h ich m ay sh ow in creased f u id w h ite blood
cell (WBC) cou n t (> 3,000/ m L), or positive Gram stain
or cu ltu res.
A PET-CT scan , tech n etiu m bon e scan , WBC scan , or
galliu m scan m ay be u se u l to aid diagn osis in in dicated
situ ation s.
Laboratory resu lts sh owed grossly elevated in f am m atory
m arkers: ESR an d CRP.
2 .2 Exp e ct e d o u t co m e
Eradication o h ip join t in ection in th e rst stage.
Main ten an ce o patien t m obility, lim b len gth , an d h ip
join t m u scle u n ction .
Provide an aseptic en viron m en t or con version to a
secon d-stage total h ip arth roplasty or lon g-term
m obility.
An in ected prosth esis at m ore th an 8 w eeks a ter
in itial su rgery is very u n likely to be cleared by a sin gle
debridem en t. Resolu tion rate u sin g a tw o-stage
revision procedu re w ith an tibiotic prosth esis in th is
situ ation is arou n d 7895% .
340
3 Pre o p e ra t ive p la n n in g
3 .1 Re m o va l o f AM p ro s t h e s is , re p la ce d w it h
a n t ib io t ic s p a ce r (firs t s t a ge )
Gen eral an esth esia (expect operation > 2 h ou rs)
Lateral position
Type an d screen o blood
First-gen eration ceph alosporin on in du ction
Au stin Moore prosth esis rem oval slide h am m er
Bon e ch isel or troch an teric osteotom y in case o
di cu lt AM prosth esis rem oval
An tibiotic prosth esis preparation :
Cem en ted cu p
Un ream ed tibial n ail as em oral stem
28 m m cobalt-ch rom e m etal em oral h ead
Van com ycin plu s gen tam icin -loaded cem en t
Postoperative system ic broad-spectru m an tibiotics,
u su ally in th e orm o com bin ation th erapy, eg,
cloxacillin an d ri am pin
Speci c an tibiotics w ill be given accordin g to th e
bacteriological sen sitivity test or at least 6 w eeks
3 .2 Re m o va l o f a n t ib io t ic s p a ce r; t o t a l h ip
re p la ce m e n t (s e co n d s t a ge a ft e r 3 6 m o n t h s)
Gen eral an esth esia
Lateral position
Type an d screen o blood
First-gen eration ceph alosporin on in du ction (or
altern ative w ith coverage o th e prim ary path ogen )
Cem en t ch isel an d cu rettes
Ultrasou n d cem en t-rem oval device
Bon e saw an d osteotom e or preparation o exten ded
troch an teric osteotom y
Troch an teric grip plate
Cable system
Cem en ted acetabu lu m an d em oral stem com pon en t
or rst-stage revision
Postoperative an tibiotics are n ot rou tin ely prescribed in
th e au th ors in stitu tion
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Tak-Wing Lau
3 .3 Pro s t h e s is t e m p la t in g
A cu stom ized h ip, sel - abricated rom in tram edu llary
n ails an d cem en ted to a m etallic h ip ball can be a
cost-e ective approach .
Altern atively, a com m ercially available cem en ted
em oral com pon en t m ay be u sed.
Th e acetabu lar com pon en t is pre erably cem en ted.
Van com ycin - plu s gen tam icin -loaded cem en t m ay be
u sed.
Prosth esis plan n in g sh ou ld aim at restorin g n orm al
acetabu lar cen ter position , n eck o set, an d n eck len gth .
A large su r ace area o cem en t allows e ective in f u en ce
o an tibiotics.
4 Su rgica l a p p ro a ch
A posterolateral approach u sin g a m ore exten sile Koch er-
Lan gen beck in cision w as u sed or both operation s. Th e
sciatic n erve m u st be care u lly iden ti ed an d protected in
all cases o revision su rgery th rou gh th is approach .
5 Su rgica l d e b rid e m e n t
5 .1 Sk in a n d s u b cu t a n e o u s la ye r
Drain age o serou s f u id an d debridem en t o gran u lation
an d n ecrotic tissu e w ith specim en s or m icrobiological
in vestigation s.
5 .2 Hip jo in t a n d fe m o ra l ca n a l d e b rid e m e n t
Radical syn ovectom y w ill redu ce in ectiou s load. Th e
in f am ed syn ovial tissu e h as a ten den cy to bleed bu t
th is is u su ally also con trolled by rem oval.
Ream in g o th e acetabu lu m u sin g acetabu lar ream ers
to rem ove in ected cartilage an d areas o osteom yelitis
in th e acetabu lu m .
Ream in g o em oral can al u sin g f exible ream er to
rem ove in ected tissu e in in tram edu llary cavity.
Pu lsatile salin e lavage u sin g a tu be in th e in tram edu l-
lary can al rom retrograde m an n er can sign i can tly
dilu te th e in ectiou s load.
Th ere is con troversy over th e u se o an tiseptics locally
in th e w ou n d.
Su rgical in stru m en ts an d gloves sh ou ld be exch an ged
a ter com pletion .
6 Im p la n t re m o va l
Th e speci c tech n iqu e in rem ovin g th e AM prosth esis is
straigh t orw ard sin ce it is u su ally loosen ed. A slide h am m er
w ith h ook is typically em ployed or th is rem oval. In a w ell-
xed in ected prosth esis care u l rem oval o obstru ction s
rom th e em oral n eck is rst per orm ed. Th e prosth esis m ay
be gen tly reverse h am m ered by u sin g speci c rem oval tools.
An exten ded troch an teric osteotom y m ay be u sed i th e
above tech n iqu e ails.
7 Te m p o ra r y fixa t io n (firs t s t a ge )
Th ere is preparation o an an tibiotic-laden prosth esis th at
w orks as a h ip join t as w ell as an an tibiotic spacer w h ere
lim b len gth an d m otion are preserved.
An tibiotic cem en t preparation sh ou ld be per orm ed u sin g
n o vacu u m an d u sin g rst-gen eration cem en tin g tech n iqu es
( n ger packin g, n o cem en t restrictor, an d n o pressu rization )
or in crease o porosity an d th u s total su r ace area.
Th e acetabu lar side sh ou ld be cem en ted in th e u su al align m en t
a ter gen tle ream in g bu t w ith ou t excessive pressu rization
allow in g or easy rem oval, yet w ith su cien t tem porary
stability.
Th e em oral com pon en t sh ou ld be im plan ted w ith m in im al
cem en t in th e deep can al an d m ostly lled at th e m etaph y-
seal area with n ger packin g an d n o pressu rization . To in crease
su r ace area, cem en t can cover th e im plan t u p to th e tru n n ion .
Th e im plan t is gen tly w obbled in rotation du rin g cem en t
cu rin g to allow a sligh tly loose t at th e cem en t-bon e in -
ter ace or easy rem oval at th e secon d stage.
Hip stability is tested w ith so t-tissu e layers care u lly opposed
to redu ced dead space. Good h em ostasis is obtain ed an d a
deep drain is n ot requ ired. Th e local an tibiotic con cen tration
is in creased by n ot placin g a deep drain .
341
 Se ct io n 3Case s
16 .4Chronically
infe cte d
hip
hemiarthroplasty
8 Po s t o p e ra t ive m a n a ge m e n t
Speci c an tibiotics, accordin g to th e cu ltu re an d sen sitivity
testin g, are given or a m in im u m o 6 w eeks. In th is case,
clarith rom ycin w as u sed to treat m eth icillin -sen sitive S au-
reus in ection . Th e du ration o an tibiotics m ay be lon ger
th an 6 w eeks, depen din g on th e clin ical respon se an d th e
seru m in f am m atory param eters. I th ere is eviden ce o
residu al in ection a ter com pletion o th e w h ole cou rse o
an tibiotics, an oth er debridem en t is per orm ed an d th e
prosth etic spacer m ay n eed to be exch an ged w ith system ic
an tibiotics accordin g to th e m ost u pdated sen sitivity test.
Th is patien t w as allow ed u ll w eigh t-bearin g w alkin g on th e
spacer a ter th e su rgery. Sh e w as advised to m obilize as soon
as possible to m in im ize th e com plication s on prolon ged im -
m obilization an d disu se atroph y. Du rin g th e ollow -u p
period, th e clin ical sign s an d sym ptom s are regu larly ch ecked
to look or reactivation o in ection . Regu lar ch eckin g o
in f am m atory param eters in clu din g ESR an d CRP is requ ired
to m on itor th e progress. A h ip join t aspiration is per orm ed
a ter 36 m on th s i th ere are n o clin ical or serological sign s
o residu al in ection to con rm eradication . Th e secon d stage
sh ou ld be w ith h eld i join t f u id WBC cou n t is still m ore
th an 3,000 cells/ L. A u rth er cou rse o an tibiotics or even
a u rth er in term ediary spacer exch an ge m ay be requ ired.
342
9 Re im p la n t a t io n (s e co n d s t a ge )
It is sa e to proceed to th e secon d stage i a join t aspirate
sh ow s n egative cu ltu re an d WBC cou n t o < 3,000 cells/ L
( or n on replaced join ts, th is is 50,000 cells/ L).
Gen eral an esth esia is u su ally pre erred as th e secon d stage
is expected to be tech n ically m ore dem an din g. Th e au th ors
u su al approach to th e h ip is a posterolateral approach . Th e
patien t is position ed in a lateral position . Usu ally, rst-
gen eration ceph alosporin is u sed or an tibiotics on in du ction ,
bu t it sh ou ld also cover th e previou s o en din g organ ism .
A ter th e skin in cision , th e sciatic n erve is care u lly iden ti ed
an d protected. Rem oval can be di cu lt i th e spacer is very
secu re in th e rst stage. An u ltrasou n d cem en t rem over
togeth er w ith an exten ded troch an teric osteotom y is som e-
tim es requ ired to rem ove th e em oral com pon en t an d cem en t
com pletely. A troch an teric stabilization im plan t w ith cable
system sh ou ld be ready in case th is osteotom y is n eeded.
Th e acetabu lar side w ill u su ally h ave sign i can t bon e de ects
eith er du e to previou s in ectiou s process or du e to debride-
m en t. Proper preoperative plan n in g an d experien ce w ith
m an agem en t o su ch de ects is n ecessary. Variou s tech n iqu es
are u sed to deal w ith th e de ect depen din g on size, location ,
an d h ow th e acetabu lar com pon en t can be w ell con tain ed.
Sm all de ects m ay be lled w ith ream ed bon e. A large-sized
acetabu lar sh ell w ith screw s is u su ally pre erred i both th e
an terior an d posterior colu m n s rem ain in tact to provide
adequ ate su pport. Altern atively, allogra ts, trabecu lar m etal
in serts, or recon stru ction cages sh ou ld be prepared or cases
w ith sign i can t de ects.
In th is case, a n on cem en ted total h ip replacem en t is per-
orm ed. For th e em u r, a revision stem with u ll-len gth porou s
coatin g is pre erred, sin ce th ere w ill be sign i can t bon e loss
proxim ally. Sign i can t proxim al em oral de ects are lled
w ith tricalciu m ph osph ate gran u les m ixed w ith ream ed bon e
h arvested rom th e acetabu lar side. Th e distal porou s portion
o th e stem m u st be secu red w ith scratch t to a len gth o
at least th ree tim es th at o th e em oral diam eter. A deep
drain is placed an d skin is closed in layers to preven t dead
space.
10 Ou t co m e
Th ere w as eradication o in ection an d th e patien t regain ed
h er m obility w ith ou t pain ( Fig 16 .4-6 a b ).
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Tak-Wing Lau
11 Pit fa lls
11.1 Dia gn o s is a n d d e cis io n m a k in g
An in ected h ip prosth esis m ay n ot presen t as an acu te
in ection bu t can be very su btle in clin ical sign s an d
sym ptom s. A h igh in dex o su spicion is requ ired
especially i :
Th e patien t h as low -grade ever w ith ou t kn ow n
cau se.
Th e patien t h as u n explain ed persisten t h ip or th igh
pain .
Th e patien t is im m u n ocom prom ised (diabetic or
steroid u ser).
Th ere is radiological eviden ce o loosen in g o
prosth esis.
Th e patien t h as persisten tly elevated ESR w ith ou t
an oth er cau se o in ection .
Radioisotope scan s provide su pplem en tal an atom ical
location in orm ation to serological tests. Th ese tests are
sen sitive bu t m ay n ot be speci c.
Patien ts w ith ragility h ip ractu res u su ally h ave
im paired cogn itive statu s an d are u n able to u lly
express th eir sym ptom s leadin g to delay in diagn osis.
11.2 Su rgica l a p p ro a ch
Posterolateral approach is th e u su al approach or h ip
replacem en t in th e au th ors cen ter. Du rin g revision
su rgery, extra care m u st be taken to iden ti y th e sciatic
n erve becau se o th e exten sive scarrin g a ter th e
in f am m atory process. Revision su rgery w ith ou t th e
iden ti cation o th e sciatic n erve cou ld lead to sciatic
n erve in ju ry.
Hem ostasis is alw ays im portan t especially in debride-
m en t su rgery. Actively in f am ed tissu es are pron e to
bleedin g. Radical debridem en t is also essen tial.
Th ere ore, extra e ort in h em ostasis is u su ally requ ired.
Th e an esth etist sh ou ld also be in orm ed abou t th e
possibility o m ore bleedin g th an a typical h ip
replacem en t.
11.3 Im p la n t re m o va l
Th e in ected prosth esis is o ten loose bu t n ot alw ays.
Failu re to ackn ow ledge in traoperative di cu lty in
rem ovin g th e prosth esis m ay resu lt in iatrogen ic
ractu re o th e acetabu lu m or th e em u r. Th is m ay
com plicate th e m an agem en t process o u sin g a spacer.
Radical debridem en t is essen tial to th e su ccess o
in ection eradication . How ever, it m ay also cau se extra
bon e loss an d w eaken in g o bon e stock.
11.4 Firs t-s t a ge t e m p o ra r y re p la ce m e n t
Th e tem porary prosth esis is an an tibiotic-loaded cem en t
spacer w ith h ip join t u n ction ( Vid e o 10-1 ). In th is case it is
sel -m ade bu t its stability m u st be good or a lim ited period
o tim e. Som e o th e com m on pit alls in a sel - abricated
prosth esis in clu de:
Loosen in g o th e em oral h ead rom th e stem
In correct n eck o set an d leg len gth
In correct em oral n eck version
Spacer im plan ted too secu rely
Cem en t placed too distally in can al
11.5 Re h a b ilit a t io n
Th e patien t is allow ed to bear u ll w eigh t on th e spacer.
Sin ce th e spacer is a tem porary sel -m ade prosth esis its
stability w ou ld be su boptim al. Hip an d th igh discom ort
w ou ld be com m on , w h ich m ay m im ic th e sym ptom o in ec-
tion reactivation . Patien ts w ith revision h ip replacem en ts,
especially a ter h ip ractu re, are at h igh er risk o dislocation .
11.6 Se co n d -s t a ge re vis io n t o t a l h ip re p la ce m e n t
Alth ou gh th e in ection param eters m ay be optim al
be ore th e de n itive su rgery, preoperative join t-f u id
m icroscopy is essen tial to decide i de n itive total join t
replacem en t sh ou ld proceed. Failu re to con rm a
sterile h ip join t be ore th e de n itive su rgery m ay resu lt
in reactivation o prosth etic in ection .
De ects in th e acetabu lu m an d em u r can be di cu lt to
deal w ith . I u n aw are, so t bon e, especially in th e
acetabu lu m , can be excessively rem oved. Care u l
preoperative plan n in g an d kn ow ledge o revision total
h ip replacem en t tech n iqu es are essen tial. Aseptic
loosin g a ter secon d-stage revision seem s to be
com m on place.
343
 Se ct io n 3Case s
16 .4Chronically
infe cte d
hip
hemiarthroplasty

11.7 Fa ilu re o f t h e ra p y 12 .2 Su rgica l a p p ro a ch

Th e spacer m ay be exch an ged as an in term ediate stage
i th ere is:
No im provem en t in clin ical eatu res o in ection .
Persisten t elevation o in ection param eters despite
appropriate an tibiotics.
Persisten t positive h ip join t aspiration in ection .
Loosen in g o spacer be ore th e secon d stage.
In ection m ay n ot be su ccess u lly treated i :
A n ew m icroorgan ism becom es establish ed or th e
organ ism develops resistan ce du rin g th e treatm en t.
Th e patien t develops com plication s rom th e
an tibiotic treatm en t w h ich in tu rn n eed to be
ch an ged or stopped.
Debridem en t o sequ estru m or in ected m aterial is
in com plete.
Th ere is ailu re to give a u ll cou rse o an tibiotics o
at least 6 w eeks.
Radical debridem en t is essen tial or th e su ccess o th e
treatm en t.
So t tissu e: com plete syn ovectom y an d rem oval o
gran u lation tissu e.
Fem oral can al: debridem en t u sin g f exible ream er an d
retrograde pu lsatile lavage o th e can al.
Acetabu lu m : care u l rem oval o cartilage an d n ecrotic
su bch on dral bon e u n til good bon e bleedin g is presen t.
Avoid excessive ream in g in so t bon e as th is m ay lead
to sign i can t bon y de ects.
Pu lsatile lavage o th e su rgical area im proves th e
su ccess o th e debridem en t.
12 .3 Im p la n t re m o va l
Exten ded troch an teric osteotom y is n ot u su ally requ ired or
a grossly in ected prosth esis bu t it sh ou ld be kept in m in d
in case o di cu lt rem oval especially i a n on cem en ted pros-
th esis m u st be rem oved.

12 Pe a rls 12 .4 Te m p o ra r y fixa t io n (re p la ce m e n t )

12 .1 De cis io n m a k in g An tibiotics added in cem en t sh ou ld best be u sed

Th e su rgeon m u st h ave a h igh in dex o su spicion in clin ical accordin g to th e sen sitivity. Com m ercially available
sign s an d sym ptom s, radiological eviden ce, an d blood pa- gen tam icin - or tobram ycin -loaded cem en t is com m on ly
ram eters: m ixed w ith van com ycin pow der in th e ratio o n ot
m ore th an 4 g to 40 g (10% by w eigh t) o cem en t or
Clin ical sign s an d sym ptom s: e ective coverage o gram -positive organ ism s w ith
Persisten t h ip or th igh pain m in im al detrim en tal e ect to its m ech an ical properties.
Low -grade ever Use o rst-gen eration cem en tin g tech n iqu e to in crease
Gen eral m alaise an d cach exia porosity, in crease su r ace area, an d redu ce excessive
Failu re to im prove du rin g reh abilitation im plan t lockin g to bon e or easier rem oval.
Spon tan eou s dislocation o a h ip prosth esis Use o sel - abricated em oral com pon en ts by u sin g
Radiological eviden ce: cem en t to secu re a m etallic h ip ball to an in tram edu llary
Presen ce o radiolu cen t lin es arou n d em oral stem n ail w ith a ben d can be a cost-e ective altern ative to
Presen ce o radiolu cen t lin es arou n d acetabu lar cu p com m ercially available m olded im plan ts.
Early su bsiden ce or ch an ge o prosth esis position De n itive revision (replacem en t).
Periosteal reaction
Blood param eters: 12 .5 An t ib io t ic m a n a ge m e n t
WBC cou n t m ay be n orm al Six w eeks o an tibiotics m ay n ot be su cien t to treat th e
CRP > 10 m g/ L in ection . Con tin u ed u se o th e appropriate an tibiotics is
ESR > 30 m m / h u su ally requ ired u n til ESR, CRP, an d h ip join t aspiration
retu rn to n orm al be ore de n itive replacem en t.

344 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Pe ter JL Je bson, David C Ring, Ge orge SM Dye r
16 .5 Ch ro n ica lly in fe cte d d is t a l ra d ia l fra ctu re
Pe te r JL Je bson , David C Ring, Ge orge SM Dye r
1 Ca s e d e s crip t io n
A 43-year-old h ealth y w om an w ith n o com orbidities pre-
sen ted w ith progressive w rist pain an d sw ellin g 6 m on th s
a ter u n dergoin g open redu ction an d in tern al xation o a
closed com m in u ted le t distal radial ractu re. Sh e su stain ed
a b
Fig 16 .5-1 a b Injury x-rays de m onstrate an unstable
com m inute d intraarticular distal radial fracture .
a Poste rolate ral vie w.
b Late ral vie w.
th e ractu re ollow in g a 4.5 m eter all on an obstacle cou rse
( Fig 16 .5-1 ). A palm ar approach was u sed an d a palm ar lockin g
plate an d screw system w ere u sed or xation ( Fig 16 .5 -2 ).
Th e postoperative cou rse w as u n even t u l an d sh e even tu -
ally retu rn ed to h er occu pation an d h obbies w ith n o loss o
w rist or orearm m otion or com plication s. At 6 m on th s
a b
Fig 16 .5-2a b Intraope rative image inte nsi cation de m onstrate s
satisfactory re duction and xation of the fracture using a palm ar
locking plate and scre w syste m . Note the am ount of dorsal
m e taphyse al com m inution.
a Poste rolate ral vie w.
b Late ral vie w.
345
 Se ct io n 3Case s
16 .5Chronically
infe cte d
distal
radial
fracture

postoperatively, sh e n oted th e spon tan eou s on set o progres- 2 In d ica t io n s

sive pain an d sw ellin g at th e su rgical site. Th ere was n o
h istory o trau m a, w ou n d drain age, evers, ch ills, or w eigh t Th e in dication to per orm su rgical m an agem en t in th is patien t
loss. X-rays revealed a qu estion ably h ealed ractu re stabilized w as based on th e w ou n d statu s, sw ellin g at th e operative
w ith a palm ar plate. Th ere w as a lu cen cy ben eath th e plate site, x-ray n din gs, an d su spected in ection . Deep in ection
in th e m etaph yseal region , possible lysis arou n d th e im plan t, ollow in g operative treatm en t o a closed distal radial rac-
an d a loose screw in th e palm ar so t tissu es ( Fig 16 .5-3 ). Sh e tu re is extrem ely rare [1, 2 ]. It is seen m ore com m on ly w ith
com plain ed o h an d n u m bn ess. Dim in ish ed sen sibility w as open ractu res o th e distal radiu s w ith an overall in ciden ce
n oted in th e m edian n erve distribu tion . o 57% [36]. Deep in ection can also occu r in th e settin g
o an extern al xator pin -track in ection , in tram edu llary
Th ese n din gs in dicated th e n eed or exploration an d n ailin g, or closed redu ction an d percu tan eou s pin n in g [7].
rem oval o all h ardw are an d possible carpal tu n n el release
depen din g on operative n din gs. Su rgical exploration w as In dication s or su rgical m an agem en t in gen eral in clu de
per orm ed u sin g th e sam e in cision . Pu ru len t m aterial w as in ected n on u n ion or m alu n ion , sepsis or bacterem ia, h ard-
en cou n tered w h en th e plate an d loose screw w ere rem oved. w are ailu re, w ou n d drain age, or n eu ropath y as n oted in
Th e ractu re w as h ealed, bu t th ere w ere several cavities th is patien t [8, 9].
w ith in th e radiu s th at requ ired exten sive debridem en t o
all in ected bon e ( Fig 16 .5 -4 ). Th e carpal tu n n el w as n ot
released becau se it was clear th at swellin g arou n d th e m edian
n erve w as directly related to th e presen ce o th e loose screw
an d th e obviou s in ection . Wou n d cu ltu res revealed Entero-
bacter cloacae. Treatm en t con sisted o a 6-w eek cou rse o oral
ciprof oxacin an d su l am eth oxazole/ trim eth oprim DS.

a
Fig 16 .5-4a b X-rays following im plant re m oval and de bride m e nt.
a Poste rolate ral vie w.
b Late ral vie w.
a b
Fig 16 .5-3a b X-rays re ve al a que stionably he ale d fracture . Note
the luce ncy be ne ath the plate in the m e taphyse al re gion, possible
lysis around the im plant, and a loose scre w in the palmar soft tissue s.
a Poste rolate ral vie w.
b Late ral vie w.

346 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Pe ter JL Je bson, David C Ring, Ge orge SM Dye r
3 Pre o p e ra t ive p la n n in g
Th e goals o treatm en t are to eradicate th e in ection , obtain
ractu re h ealin g, an d restore u n ction . Preoperative w orku p
sh ou ld in clu de serological testin g (eryth rocyte sedim en ta-
tion rate, C-reactive protein (CRP), w h ite blood cell cou n t
w ith di eren tial) an d plain x-rays o both th e in volved an d
u n in volved w rist to determ in e th e n orm al an atom y. Com -
pu ted tom ograph y (CT) can be particu larly h elp u l in de-
term in in g th e exten t o ractu re h ealin g an d presen ce o a
n idu s an d/ or sequ estru m . Review o th e previou s operative
n ote(s) is im perative to determ in e th e type o im plan t u sed
i applicable. Appropriate equ ipm en t th at sh ou ld be available
in th e operatin g room in clu des cu rettes, osteotom es, a screw
rem oval set, extern al xation , bu rr, an d an tibiotic-laden
polym eth ylm eth acrylate cem en t, w h ich m ay be u sed as a
tem porary spacer. A n egative-pressu re w ou n d dressin g m ay
be n ecessary i th e operative w ou n d is too large to close
im m ediately.
4 Su rgica l a p p ro a ch
Th e in cision type an d location are based on th e location o
an y prior in cision (s), associated n erve com pression , h ardware
location , w ou n d statu s, presen ce o drain in g w ou n ds/ sin u s
tracts, an d th e location o th e in ection locu s/ n idu s. Th is
decision can be determ in ed a ter care u l ph ysical exam in ation
an d critical review o diagn ostic im agin g.
Gen eral or region al an esth esia m ay be u sed. Th e patien t is
position ed su pin e, an arm board is u sed, a pn eu m atic tou r-
n iqu et is applied bu t on ly u sed w ith ou t Esm arch exsan gu i-
n ation to avoid orcin g in ectiou s m aterial proxim ally with in
th e orearm . Proph ylactic an tibiotics are h eld u n til in traop-
erative w ou n d cu ltu res h ave been obtain ed.
Th e su rgical approach is o ten tediou s an d can be ch allen g-
in g becau se o scarrin g an d a loss o n orm al tissu e plan es
an d an atom ical lan dm arks. I th e ractu re h as sh orten ed
sign i can tly as a resu lt o h ardw are ailu re, releasin g th e
brach ioradialis an d m obilizin g th e dorsal periosteu m an d
so t tissu es can be h elp u l in restorin g len gth . Occasion ally,
Z-len gth en in g o th e w rist lexors m ay be n ecessary in
severely sh orten ed an d in ected m alu n ion s.
5 Su rgica l d e b rid e m e n t
All n on viable devitalized bon e an d so t tissu e sh ou ld be
debrided w h ile preservin g n erves an d arteries. Debridem en t
is per orm ed u sin g a com bin ation o a n u m ber 15 scalpel
blade, ten otom y scissors, ron geu r, cu rettes, an d osteotom es.
Alth ou gh classic teach in g em ph asizes th e u se o a rou n d
bu rr to th orou gh ly debride in ected cortical bon e, th e bon e
in th e distal radiu s is o ten so t en ou gh to debride w ith ou t
pow er equ ipm en t [10 ]. Addition ally, th e proxim ity o th e
m edian n erve an d radial artery can m ake bu rr u se dan gerou s.
Follow in g adequ ate debridem en t, copiou s w ou n d irrigation
sh ou ld be per orm ed. Represen tative bon e an d tissu e sh ou ld
be sen t or m icrobiology (aerobic, an aerobic, u n gal cu ltu res,
Gram stain ) an d or h istopath ology exam in ation . For severe
in ection s, serial debridem en ts m ay be n ecessary.
6 Im p la n t re m o va l
Th is case w as straigh t orw ard. Th e im plan t w as som ew h at
loose bu t th e m ajority o th e ractu re h ad h ealed an d w as
deem ed stable. I th ere is in adequ ate ractu re h ealin g, th e
im plan t m ay n eed to be replaced/ retain ed an d on ly rem oved
a ter adequ ate u n ion h as been con rm ed on x-rays an d CT
scan . I th e im plan t is w ell xed, u se th e correct in stru m en t
set associated w ith th e particu lar im plan t. In som e cases,
im plan t rem oval can be ch allen gin g. Stripped screw h eads
m ay be rem oved w ith an easy-ou t or by takin g th e screw
h ead o w ith an osteotom e th en overdrillin g th e rem ain in g
screw sh a t w ith a can n u lated drill ollow ed by extraction
w ith a n e n eedle-n ose pliers, lockin g vice grips, or large
n eedle h older. Broken screw s m ay be rem oved in a sim ilar
ash ion . Plates m ay be elevated w ith an osteotom e or key
elevator. I h ardw are is broken , all pieces m u st be rem oved
i possible an d accou n ted or. Portable im age in ten si cation
can be h elp u l in th is regard.
347
 Se ct io n 3Case s
16 .5Chronically
infe cte d
distal
radial
fracture
7 Te m p o ra r y fixa t io n
Follow in g debridem en t an d im plan t rem oval, th e radiu s
m ay be u n stable n ecessitatin g im m obilization . A care u lly
applied an d appropriately m olded cast m ay be su cien t.
Tem porary u se o an extern al xator is a h elp u l altern ative
to m ain tain len gth an d stabilize th e so t tissu es. Care m u st
be taken w h en applyin g th e xator su ch th at th e pin s are
in serted ou tside o th e zon e o in ection . In sertion o an
an tibiotic-laden polym eth ylm eth acrylate spacer or large
bon e resection preserves len gth , lls th e de ect, an d delivers
an tibiotics in h igh con cen tration .
8 Po s t o p e ra t ive m a n a ge m e n t
Postoperatively, th e lim b is splin ted or com ort an d elevated.
Th e patien t is en cou raged to per orm im m ediate n ger an d
th u m b ran ge-o -m otion exercises. I a w ou n d drain w as
placed, it sh ou ld be rem oved 2448 h ou rs postoperatively.
Th e lim b is n ot u sed or weigh tbearin g activities. Con su ltation
with an in ectiou s diseases specialist is h igh ly recom m en ded
to determ in e th e treatm en t regim en , m eth od o an tibiotic
delivery (in traven ou s, oral, or com bin ation ), an d ollow th e
patien t respon se in clu din g rou tin e serological testin g ( or
CRP). Su pplem en tal below -elbow bracin g m ay be n ecessary
i a cast is n ot u sed. I applicable, th e patien t is in stru cted
on an d in itiates extern al xator pin -site care w h en th e su -
tu res are rem oved 2 w eeks postoperatively. Th e patien t is
en cou raged to per orm requ en t exercises to redu ce edem a,
im prove ran ge o m otion , an d h an d u n ction . Patien ts th at
n eed m ore teach in g an d coach in g, or addition al cam araderie
can w ork w ith a h an d th erapist.
9 Re im p la n t a t io n
Reim plan tation or revision in tern al ixation is u su ally
per orm ed a m in im u m o 6 w eeks postoperatively bu t th e
exact tim in g is based on th e patien ts overall h ealth statu s,
th e statu s o th e so t tissu es, th e respon se to th e an tibiotic
regim en , an d ollow in g a discu ssion w ith th e in ectiou s
diseases con su ltan t. Reim plan tation sh ou ld on ly occu r a ter
th e in ection h as been eradicated, th e w ou n d h as h ealed,
an d so t-tissu e h om eostasis is apparen t w ith m in im al or n o
edem a an d good n ger an d th u m b m otion . Th e patien t
sh ou ld n ot h ave an y system ic sym ptom s su ch as persisten t
348
ever, th eir n u trition al statu s m u st be optim ized, an d a
n orm al CRP con rm ed. Th e eryth rocyte sedim en tation rate
can be persisten tly elevated or several m on th s an d sh ou ld
n ot be u sed to determ in e tim in g o reim plan tation .
Wh en reim plan tation is per orm ed, th e type o proph ylactic
an tibiotics u sed sh ou ld be based on th e prior w ou n d cu ltu re
resu lts an d recom m en dation s o th e in ectiou s diseases
con su ltan t. An tibiotics are u su ally con tin u ed u n til drain
rem oval at 48 h ou rs postoperatively. Th e con tin u ed u se o
su ppressive an tibiotics ollow in g revision in tern al xation
is n ot typically n ecessary i th e in ection h as been com -
pletely eradicated. How ever, th e n eed or u se is determ in ed
by th e treatin g su rgeon an d in ectiou s diseases con su ltan t.
Th e type o su rgical approach is based on several actors
in clu din g th e location o an y prior in cision s, th e statu s o
th ose in cision s, th e presen ce an d location o an y drain in g
sin u s, an d th e type o im plan t selected. An exten sile expo-
su re is n ecessary an d m ay in volve a dorsal, palm ar, or a
com bin ation o approach es. Th e su rgeon sh ou ld con sider
th e u se o a lockin g plate or plates becau se o disu se osteo-
pen ia. Th e plate n eeds to be lon g en ou gh to provide adequ ate
xation in th e distal m etaph ysis an d su bch on dral region s.
I a corticocan cellou s gra t is u sed, screw s m ay be in serted
th rou gh th e plate an d in to th e gra t. I th ere is n ot en ou gh
bon e distally or im plan t pu rch ase or i th e radiocarpal join t
is dam aged, w rist u sion is recom m en ded [11].
For m etaph yseal bon e de ects less th an 5 cm , au togen ou s
corticocan cellou s or can cellou s bon e gra t rom th e iliac
crest is pre erred. Th e iliac crest sh ou ld be prepped bu t th e
gra t is h arvested on ly a ter th e distal radiu s h as been
exposed an d debrided an d n o active in ection con rm ed.
Th e su rgical team sh ou ld u se separate gloves, gow n s, an d
in stru m en ts to avoid cross-con tam in ation . I th e de ect is
larger, a vascu larized- ree bu la gra t is pre erred [12].
In traoperative w ou n d cu ltu res w ith a tissu e Gram stain
sh ou ld be obtain ed. Th e au th ors recom m en d a m in im u m
o th ree sam ples obtain ed rom di eren t w ou n d location s.
Th e n eed or con tin u ed postoperative an tibiotics is based
on th e operative n din gs, in traoperative cu ltu re resu lts,
prior respon se to th e an tibiotic regim en , an d recom m en da-
tion s o th e in ectiou s diseases con su ltan t.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Pe ter JL Je bson, David C Ring, Ge orge SM Dye r
10 Ou t co m e
Th e patien t w as doin g w ell at th e 4-m on th ollow -u p a ter
th e last su rgery w h en sh e cam e in or an u n related reason .
Sh e con tin u ed to experien ce occasion al ach in g in th e w rist.
Sh e h ad u ll ran ge o m otion o th e n gers, w rist, an d ore-
arm , an d n o n u m bn ess. Th ere w as n o recu rren ce o th e
in ection an d th e ractu re even tu ally h ealed ( Fig 16 .5-5 ).
11 Pit fa lls
On e o th e m ost com m on pit alls in th e m an agem en t
o th e patien t w ith an in ected distal radial ractu re is a
delay in th e diagn osis an d in itiation o appropriate
treatm en t. Th e su rgeon o ten ails to con sider or
recogn ize a deep in ection or treats th e patien t w ith a
cou rse o oral an tibiotics or an in correctly diagn osed
cellu litis in lieu o aggressive debridem en t, w ou n d
cu ltu re, an d possible h ardw are rem oval.
An oth er pit all is th e ailu re to per orm an adequ ate
debridem en t. All devitalized in ected bon e an d so t
tissu es sh ou ld be excised preservin g im portan t n erves,
arteries, an d vein s. Th e su rgical team m u st rem em ber
to obtain appropriate tissu e specim en s or m icrobiology
an d h istopath ology.
a b
Fig 16 .5-5a b X-rays at the 4 -m onth follow-up.
a Poste rolate ral vie w.
b Late ral vie w.
A com m on m istake is to leave th e h ardw are in w h en
stability is qu estion able or n ot h ave th e correct
equ ipm en t to acilitate rem oval. Failu re to adequ ately
su pport th e u n stable w rist ollow in g im plan t rem oval
an d debridem en t resu lts in u rth er so t-tissu e trau m a,
m ay be pain u l w ith m ovem en t, an d ails to m ain tain
lim b len gth an d align m en t w ith resu ltan t m yoten di-
n ou s sh orten in g, loss o m otion , an d con tractu re
developm en t.
In adequ ate reh abilitation m ay resu lt in a sti , sw ollen
h an d w ith sign i can t u n ction al loss.
Un recogn ized an d u n treated n erve com pression m ay
resu lt in com plex region al pain syn drom e.
Addition al pit alls at reim plan tation in clu de u sin g too
sh ort a plate w ith in adequ ate stability an d loss o
xation , u sin g a n on lockin g plate in osteopen ic bon e
w ith resu ltan t poor screw pu rch ase an d stability, n ot
u sin g an adequ ate volu m e o bon e gra t, an d n ot u sin g
au togen ou s bon e gra t.
12 Pe a rls
Alw ays h ave a h igh in dex o su spicion o th e patien t
w h o presen ts w ith cellu litis or drain in g sin u s a ter a
distal radial ractu re particu larly i th e ractu re w as
open an d con tam in ated, u n derw en t open redu ction
in tern al xation , or h ad an in ected percu tan eou sly
in serted K-w ire.
Th e au th ors recom m en d con su ltation w ith an in ectiou s
diseases specialist.
Th e su rgical approach sh ou ld be based on th e location
o th e:
Prior in cision (s)
Drain in g sin u s, i presen t
Nidu s iden ti ed on plain x-rays or CT scan
An exten sile approach is particu larly h elp u l. Review
th e previou s operative n ote(s) to determ in e th e type o
im plan t an d m ake su re you h ave all appropriate
equ ipm en t ordered an d available in th e operatin g
th eater be ore you begin th e procedu re.
Adequ ate debridem en t con sists o th e rem oval o all
in ected devitalized avascu lar bon e an d so t tissu e
except im portan t stru ctu res su ch as th e radial an d
u ln ar arteries an d m edian an d u ln ar n erves.
Alw ays obtain adequ ate an d represen tative specim en s
or m icrobiological an alysis, in clu din g a Gram stain
(aerobic an d an aerobic), an d u n gal cu ltu res.
349
 Se ct io n 3Case s
16 .5Chronically
infe cte d
distal
radial
fracture
Th e decision to rem ove an y h ardw are is based on th e
ractu re an d w ou n d statu s. I th e ractu re is u lly
h ealed or th e im plan t is loose, rem oval o all h ardw are
is recom m en ded. I th e ractu re is n ot h ealed an d th e
im plan t is w ell xed, th e im plan t m ay be replaced or
retain ed. Th ese im plan ts are typically coated w ith a
bio lm .
Mu ltiple debridem en ts m ay be n ecessary an d sh ou ld be
per orm ed every 4872 h ou rs.
Th e decision to per orm reim plan tation is based on
several actors an d sh ou ld be don e in con ju n ction w ith
th e in ectiou s diseases con su ltan t.
I tem porary extern al xation is u sed, th e pin s sh ou ld
be in serted ou tside o th e su rgical/ in ection zon e.
Restore len gth a ter h ardw are rem oval.
Th e u se o a postoperative drain sh ou ld be con sidered
i sign i can t bleedin g an d/ or edem a is an ticipated
ollow in g debridem en t. Hem atom a orm ation sh ou ld
be avoided.
Con sider a proph ylactic carpal tu n n el release i th e
patien t h as an y sym ptom s o m edian n erve com pression
or a h istory o carpal tu n n el syn drom e in th e past th at
w as treated n on operatively.
Wh en per orm in g de n itive xation , a lockin g plate
an d screw s are recom m en ded i th e bon e is osteopen ic
or a large bon e de ect is n oted ollow in g debridem en t.
Care u l preoperative plan n in g is im perative to m ake
su re th at th e plate is lon g en ou gh . Altern atively,
con sider dorsal bridge platin g to com pletely avoid th e
orm er zon e o in ection an d to m in im ize relian ce on
osteopen ic m etaph yseal periarticu lar bon e.
I th e radiu s is sh orten ed, release th e brach ioradialis
an d dorsal periosteu m to m obilize th e distal ragm en t.
Th e u se o in traoperative tem porary extern al xation
to restore len gth prior to plate application m ay be
h elp u l. Despite th ese m easu res, you m ay n ot be able
to recover u ll radial len gth an d th e distal radiou ln ar
join t an d u ln a itsel m ay n eed to be addressed to avoid
im paction , sym ptom atic in stability, or in con gru en cy.
Th e au th ors pre eren ce or llin g de ects less th an
5 cm is au togen ou s corticocan cellou s or can cellou s
bon e gra t rom th e iliac crest. Larger de ects m ay
requ ire a vascu larized- ree bu lar gra t.
Th e n eed or postoperative an tibiotics is u su ally
determ in ed in con ju n ction w ith th e in ectiou s diseases
specialist an d is based on several actors in clu din g th e:
type o in ectin g organ ism (s), respon se to th e preop-
erative an tibiotic regim en , in traoperative n din gs, an d
patien ts overall h ealth statu s.
350
13 Re fe re n ce s
1. Es e n w e in P, So n d e re gge r J, Gru e n e rt J, e t a l. Com plication s
ollow in g palm ar plate xation o d istal rad iu s ractu res: a
review o 665 cases. Arch Orthop Trauma Surg.
2013;133(8):1155 1162.
2. Ta ra llo L, Mu gn a i R, Za m b ia n ch i F, e t a l. Volar plate xation or
th e treatm en t o distal rad iu s ractu res: an alysis o adverse
even ts. J Orthop Trauma. 2013;27(12):74 0 745.
3. Glu e ck DA, Ch a ro glu CP, La w t o n JN. Factors associated w ith
in ection ollow in g open d istal rad iu s ractu res. Hand.
2009;4(3):330 334.
4. Zu m s t e g JW, Mo lin a CS, Le e DH, e t a l. Factors in f u en cin g
in ection rates a ter open ractu res o th e rad iu s an d/or u ln a.
J Hand Surg Am. 2014;39(5):956 961.
5. Ro ze n t a l TD, Be re d jik lia n PK, St e in b e rg DR, e t a l. Open
ractu res o th e d istal rad iu s. J Hand Surg Am. 2002;27(1):7785.
6. Ku r ylo JC, Axe lro d TW, To rn e t t a P 3rd ,
e t a l. Open ractu res o th e d istal rad iu s: th e e ects o delayed
debridem en t an d im m ediate in tern al xation on in ection rates
an d th e n eed or secon dar y procedu res. J Hand Surg Am.
2011;36(7):11311134.
7. Bo t t e MJ, Da vis JL, Ro s e BA, e t a l. Com plication s o sm ooth pin
xation o ractu res an d dislocation s in th e h an d an d w rist.
Clin Orthop Relat Res. 1992;(276):194 201.
8. Sh ie ld s DW, Els o n DW, Ma rs h M, e t a l. Catastroph ic
osteom yelitis ollow in g percu tan eou s w ire xation o a d istal
rad ial ractu re: a cau tion ar y tale o poor patien t selection
ollowed by su rgical m ish ap. BMJ Case Reports. 2013;13.
9. Bird s a ll PD, Miln e DD. Toxic sh ock syn drom e du e to
percu tan eou s Kirsch n er w ires. Injury. 1999; 30(7):509 510.
10. Te t s w o rt h K, Cie rn y G 3rd . Osteom yelitis debridem en t
tech n iqu es. Clin Orthop Relat Res. 1999;(360):8796.
11. Pro m m e rs b e rge r KJ, Fe rn a n d e z DL, Rin g D, e t a l. Open
redu ction an d in tern al xation o u n -u n ited ractu res o th e
d istal radiu s: does th e size o th e d istal ragm en t a ect th e
resu lt? Chir Main. 2002 Mar;21(2):113 123.
12. Ch in KR, Sp a k JI, Ju p it e r JB. Septic arth ritis an d osteom yelitis o
th e w rist: recon stru ction w ith a vascu larized bu lar gra t.
J Hand Surg Am. 1999;24(2):243 24 8.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Pe ter E Ochsne r

17 Acu te o s te o m ye litis o f th e fe m u r
Pe te r E Ochsn e r

1 Ca s e d e s crip t io n Even tu ally, th e patien t com plain ed on ly o pain in th e le t

A 34-year-old em ale ph ysioth erapist h ad experien ced som e
w eakn ess in h er le t leg or som e tim e. Sh e su ered rom
in som n ia an d loss o appetite. An even in g o jazz dan cin g
w as ollow ed by w orsen in g pain in th e th igh m u scles. An
exam in ation by u ltrasou n d o th e th igh su ggested a m u scle
tear an d bleedin g. Ten days later th e patien t n oted a sligh t
ever th at w as accom pan ied by sh ivers a ter 3 days.
th igh . X-rays an d a com pu ted tom ograph ic scan o th e em u r
w ere per orm ed ( Fig 17-1 ). Th e den sity o th e bon e m arrow
w as elevated in dicatin g an in ection o th e m edu llary can al.
Com pu ted tom ograph y w ith iodin ated con trast m ediu m
also revealed su rrou n din g so t-tissu e en h an cem en t. Osteo-
m yelitis rath er th an a m align an t tu m ou r w as su ggested,
w h ich w as con cordan t w ith th e h istory an d exam in ation
n din gs.

Sh e w en t to th e h ospital em ergen cy departm en t w ith a

tem peratu re o 40.1 C; h er eryth rocyte sedim en tation rate
w as 31 m m / h an d leu kocyte cou n t 7,300 cells/ L w ith 87%
gran u locytes. Accordin g to th e adm ission n ote, th e th igh
w as ou n d to h ave lateral ten dern ess w ith ou t in f am m ation .
It w as th ou gh t to be a trau m atic even t u n related to th e
actu al in f am m atory process. Tw o blood cu ltu res w ere taken
ollow ed by in traven ou s an tibiotic th erapy w ith ce azolin
(2 g every 6 h ou rs) an d gen tam icin (80 m g every 8 h ou rs).
Hepatom egaly an d splen om egaly w ere also n oted on u l-
trasou n d exam in ation . A liver biopsy sh ow ed sign s o in -
f am m ation probably triggered by a gen eral in ection . Th e
C-reactive protein in creased to 108 m g/ L tw o days a ter
begin n in g treatm en t w ith an tibiotics. A ter a secon d episode
o ever o 39.1 C w as recorded on th e th ird h ospital day,
th e tem peratu re rem ain ed ~ 37.4 C. On e blood cu ltu re
grew ou t Streptococcus milleri on th e th day.
a b c
Fig 17-1 a c The le ft fe mur.
a b AP and late ral x-ray: distinct thicke ning of the late ral corte x and
the line a aspe ra ove r a le ngth of 12 cm com bine d with signs of
oste oporosis.
c Ce ntral se ction of the com pute d tom ography: local oste olytic
are a in the ce ntre of the line a aspe ra.

351
 Se ct io n 3Case s
17 Acute
oste omyelitis
of
the
femur

2 In d ica t io n s 3 Su rgica l p ro ce d u re

On h ospital day 6, th e orth opedic su rgeon w as con su lted.
Th e n din gs su ggested th e diagn osis o an acu te in ection
on th e basis o a prim ary ch ron ic in tracortical osteom yelitis
w ith possible exten sion in th e m edu llary cavity an d adjacen t
so t tissu es leadin g to an acu te in ection . Su rgical rem oval
o th e n idu s an d drain age o th e m edu llary can al w as plan n ed.
Exposu re w as obtain ed u sin g a lateral in cision . Th e lin ea
aspera w as exposed w h ere a 15 m m diam eter abscess w as
ou n d. Th e lin ea aspera w as so ten ed an d th icken ed. Th e
m ost prom in en t part w as rem oved w ith a ch isel exposin g
w h ere som e yellow pu s em erged ( Fig 17-2 ). A en estration
o th e em u r rom th e posterior side w as per orm ed. Fou r
drill h oles (3.2 m m diam eter) w ere placed at th e site o th e
plan n ed corn ers o th e cortical w in dow , w h ich w ere th en
con n ected with an oscillatin g saw ( Fig 17-3a ). In th e m edu llary
cavity, pu s w as presen t an d th ere ore drain ed. Addition al
pu s w as evacu ated. Th e m edu llary cavity w as cu retted,
irrigated, an d exten sively drain ed. Th e pu s an d tw o in tra-
operative tissu e sam ples w ere h arvested. All m icrobiological
testin g rem ain ed n egative.

a b
Fig 17-2 The poste rior aspe ct of the fe mur afte r chise lling away the thicke ne d line a Fig 17-3 a b Postope rative follow up x-rays:
aspe ra. In the ce ntre ye llow granulation tissue be com e s visible . a The bone window with drill hole s in the
four e dge s.
b Fracture through the lowe r e nd of the
window 18 days postope rative ly.

352 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Pe ter E Ochsne r

4 His t o lo gica l a n a lys is 6 Co m p lica t io n

Th e h istological sam ples w ere processed w ith ou t decalci ca-
tion . Th e th icken ed lin ea aspera w as osteoporotic ( Fig 17-1a ,
Fig 17-4 a ). It con tain ed n u m erou s w ide lon gitu din al ch an n els
w ith sign s o active en largem en t ( Fig 17-4b ). In f am m atory
cells w ere presen t di u sely. Togeth er, th ese n din gs su g-
gested an acu te in ection su perim posed on ch ron ic in ection
( Fig 17-4 b c ).
Eigh teen days a ter en estration th e patien t tried to stan d
u p rom a low so a an d elt a crack, accom pan ied by severe
pain . Th e x-ray presen ted a sligh tly displaced spiral em oral
ractu re th rou gh th e w in dow ( Fig 17-3 b ). Open redu ction
an d in tern al xation was th en per orm ed. Th e in traoperative
redu ction w as h eld u sin g tw o Weber clam ps an d xed w ith
tw o 3.5 m m lag screw s protected by a plate osteosyn th esis.
Mobilization w as allow ed w ith 15 kg u sin g tw o cru tch es.
Fu ll w eigh t bearin g w as perm itted a ter 3 m on th s.

5 Po s t o p e ra t ive m a n a ge m e n t

An tibiotic th erapy w ith in traven ou s ce azolin or 6 w eeks

w as given u sin g a port--cath system th u s allow in g am bu -
latory in traven ou s th erapy. C-reactive protein n orm alized
w ith in 2.5 w eeks. Fu ll w eigh t bearin g u sin g cru tch es w as
allow ed or 8 w eeks.

a c

b
Fig 17-4a c Histological analysis using a te chnique without de calci cation.
a Microradiograph of a transve rse se ction of the line a aspe ra at the le ve l of the m ost radioluce nt aspe ct ( Fig 17-1c ): chronic change s with
rare faction of the osse ous structure . The re is no re al ce ntral nidus com parable with an oste oid oste om a.
b Longitudinal se ction adjace nt to the se ction in Fig 17-4 a (von Kossa stain se ction): ne wly form e d wide longitudinal channe l line d with
m any oste oclasts e ating away the cortical bone structure . The ce nte r contains only chronic in amm atory ce lls.
c Magni e d de tail (Goldne r stain) with distinct acute infe ction containing many se gm e nte d granulocyte s.

353
 Se ct io n 3Case s
17 Acute
oste omyelitis
of
the
femur

7 Ou t co m e 8 Co m m e n t

Th e 11-year ollow -u p dem on strated u ll recon stru ction o
th e em u r, bu t a de ect rem ain ed in th e area o th e lin ea
aspera ( Fig 17-5 ). Th e patien t n oted sligh t recu rren t pain or
several years. Tw en ty-th ree years a ter on set, th e patien t is
com pletely pain ree, rem arkin g a sligh t w eakn ess o th e
le t leg.
An acu te in ection occu rred in a patien t th at presen ted w ith
a very sh ort h istory o local ten dern ess at th e th igh , prim ar-
ily n ot bein g con sidered as th e sou rce o th e acu te gen eral
in ection , accom pan ied by h epatosplen om egaly an d im pres-
sive seru m in f am m atory m arkers. Th e local in ection m u st
h ave developed over a period o m on th s ju dgin g by th e
h istological ch an ges ( Fig 17-4 ) an d th e osteoporotic ch an ges
ou n d in th e lin ea aspera. Th e cau se o th e acu te on set o
in ection w as u n clear.

a b c
Fig 17-5a c X-rays showing the situation afte r oste osynthe sis.
a Postope rative ly.
b c Afte r 11 ye ars.

354 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Pe ter E Ochsne r
9 Pit fa lls
Du rin g th e clin ical presen tation o in ection , th e
osseou s origin o th e in ection w as m issed.
Th e w eaken in g o th e bon e stru ctu re by th e posterior
bon e w in dow w as su ch th at a atigu e ractu re th rou gh
th e in erior part o th e bon e w in dow occu rred. In th e
ollow in g years th e au th or th ere ore ch an ged th e
tech n iqu e to an oval-sh aped bon e en estration begin n in g
w ith tw o drill h oles o a larger diam eter (810 m m
diam eter), w h ich are th en in tercon n ected w ith an
oscillatin g saw ( Fig 17-6 ).
Fig 17-6 Modi e d te chnique for bone fe ne stration: inste ad of sm all drill hole s
(3 .5 m m diam e te r) in the corne rs, two large drill hole s ( 8 10 m m) are place d at
the e nd of the planne d window signi cantly diminishing the risk of fracture .
10 Pe a rls
It is rem arkable h ow a sm all local area o bon e in ection
w ith h istological sign s o ch ron ic prim ary developm en t
can provoke su ch an acu te in ection .
Th is is a very rare case o in tracortical in ection leadin g
to an acu te developm en t.
Th e clin ical pictu re o acu te in ection h elped to ru le
ou t a m align an t bon e tu m ou r.
11 Ack n o w le d ge m e n t s
Th e h istological section s w ere carried ou t by Peter Zim m er-
m an n in th e laboratory or u n decalci ed h istology ru n by
th e au th ors departm en t or orth opedic su rgery at th e
Kan ton sspital Liestal, an d Stratec AG, Oberdor , Sw itzerlan d.
355
 Se ct io n 3Case s
17 Acute
oste omyelitis
of
the
femur

356 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Pe ter E Ochsne r
18 Ch ro n ic o s te o m ye litis o f th e tib ia
Pe te r E Ochsn e r
1 Ca s e d e s crip t io n
A 34-year-old m an developed sw ellin g in th e orearm an d
th e low er leg. A ten dern ess o th e an terior leg com partm en t
w as n oted. Six w eeks later, eryth rocyte sedim en tation rate
(ESR) w as 10 m m / h an d h em oglobin (Hb) 147 g/ L. Hom eo-
path ic th erapy w as attem pted w ith partial pain relie a ter.
Tw o-an d-a-h al m on th s a ter th e on set o sym ptom s, local
sw ellin g an d w arm th w ere m ore prom in en t. An x-ray o
th e distal tibia sh ow ed su spiciou s cortical ch an ges ( Fig 18-1a ).
A m agn etic reson an ce im agin g stu dy dem on strated an
osteolysis o th e lateral an d posterior cortical bon e w ith
periosteal sw ellin g alon g th e w h ole tibial sh a t in th is area.
Th e radiologist su ggested a di eren tial diagn osis o telan -
giectatic osteosarcom a, m align an t brou s h istiocytom a,
n on -Hodgkin s lym ph om a, an d Ew in g sarcom a. Th e patien t
th ere ore w as re erred to th e m u scu loskeletal on cology
a b c d
departm en t or u rth er diagn osis. Th ree-ph ase bon e scin -
tigraph y sh ow ed activity in th e distal part o th e tibia;
an giograph y did n ot sh ow path ological vessels; com pu ted
tom ograph ic scan o th e th orax an d abdom en w ere n egative.
A secon d x-ray o th e low er tibia presen ted a sligh t progres-
sion o th e periosteal ossi cation ( Fig 18 -1b ). In th e absen ce
o clear sign s o in ection , a biopsy w as proposed bu t re-
jected by th e patien t. Th e patien t attem pted treatm en t w ith
h om eopath ic dru gs.
Six m on th s a ter on set, ESR w as 7 m m / h . A n ew x-ray o
th e tibia presen ted a sh arp delim itation o th e cortical bon e
( Fig 18-1 c ). Th e radiologist added ch ron ic osteom yelitis as a
u rth er option to th e origin al di eren tial diagn osis o m a-
lign an t tu m ou rs. On e m on th later th e patien t presen ted
w ith a progressive sw ellin g w ith ESR 52 m m / h , Hb 133 g/ L,
leu kocytes 14,400 cells/ L, in clu din g 9,550 gran u locytes.
Fig 18-1a d De ve lopm e nt of the
radiological change s in the le ft tibia.
a b Ove rvie w ( a ) and de tail ( b ) of the rst
x-ray, 2 .5 m onths afte r onse t. Localize d
thicke ning of the late ral corte x by ne w
pe rioste al bone form ation without a
cle ar-cut borde rline . Thinning of the
original corte x.
c Two we e ks late r the pe rioste al bone is
thicke ne d.
d Four m onths late r the pe rioste al
thicke ning of the corte x is consolidate d
with sharp de m arcation. The arrow
indicate s ante rolate ral cortical
pe rforation ( Fig 18-2c ).
357
 Se ct io n 3Case s
18 Chronic
oste omye litis
of
the
tibia
2 In d ica t io n s
Tw o w eeks later, 7.5 m on th s a ter th e on set o sw ellin g,
acu te progression w as observed. At h ospitalization a local
area o f u ctu ation w as eviden t ( Fig 18 -2 ). Th e patien t pre-
sen ted w ith ever o 38.2 C, Hb 12 g/ L, leu kocytes 19,100
cells/ L (80% gran u locytes), C-reactive protein 147 m g/ L,
ESR 122 m m / h . In cision o th e sw ellin g evacu ated abou t
200 cc o pu s. Treatm en t w as started w ith am oxicillin / cla-
vu lan ic acid 2.2 g th ree tim es per day in traven ou sly. A plaster
splin t w as applied. Th e m icrobiological an alysis presen ted
-h aem olytic streptococci an d coagu lase-n egative staph y-
lococci a ter 4 days.
b follows. The re m ove d se gm e nt the n unde rgoe s histological analysis.
c
Fig 18-2a c Patie nt im age s.
a Lowe r le g im m e diate ly prior to incision.
b Two days late r.
c Late ral incision, pre se nting the ante rior spontane ous pe rforation
of the corte x allowing the pus to re ach the subcutane ous re gion.
358
3 Su rgica l p ro ce d u re
Th e plan or su rgery w as to evacu ate th e in tram edu llary
abscess w ith an y sequ estra. Th e in ten tion w as to create a
lateral cortical w in dow ( Fig 18 -3 ) an d cu rette th e m edu llary
cavity. Th e su rgical approach w as ch osen rom lateral in th e
area o th e m ost eviden t radiological ch an ges givin g a view
o th e an terior per oration ( Fig 18 -2 c ) an d th e plan n ed w in -
dow . From th e bon e su r ace a th in n ew periosteal bon e
layer w as rem oved togeth er w ith th e periosteu m . A ter drill-
in g ou r h oles (3.2 m m diam eter) th e w in dow w as created
w ith an oscillatin g saw . Th rou gh th is open in g, cu rettage o
th e m edu llary cavity ollow ed in clu din g ream in g aw ay th e
in n er parts o th e cortex to rem ove sequ estered bon e.
Spontaneous
perforation
Resected segment
Drill holes
Fig 18-3 Surgical plan: a late ral se gm e nt is re se cte d afte r placing
drill hole s in the four e dge s. The n a thorough cure ttage of the cavity
a
b
Fig 18-4a b Approach and additional incision.
a Suture d late ral approach and drainage .
b Me dial vie w of the suture d ante rior incision and an additional
poste rior incision to re lax the skin te nsion, re ady for late r
closure .
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Pe ter E Ochsne r

Th ree tissu e specim en s w ere obtain ed an d all w ere n egative.
Becau se o th e local sw ellin g, an addition al dorsom edial
in cision prepared or delayed closu re w as placed to relax
th e local ten sion w h en th e w ou n ds w ere closed ( Fig 18-4a b ).
4 His t o lo gica l a n a lys is
Th e resected bon e segm en t an d som e cu rettage m aterial o
th e m edu llary cavity u n derw en t u n decalci ed h istological
an alysis. Th e bon e rem oved w ith th e periosteu m con sisted
o n ew ly orm ed bon e areas con tain in g a great percen tage
o osteoid an d osteoblasts. Th en ollow ed a th ick layer o
com pact periosteal bon e, rich ly vascu larized ( Fig 18 -5 ,
Fig 18 -6 a ),arran ged m ore in a radial m an n er n ot sh ow in g a
classic com position with osteon s. From th e origin al cortical
bon e on ly dead-bon e islan ds rem ain ed, h avin g a brittle
aspect, presen tin g on ly em pty osteocyte cavities ( Fig 18 -5 ,
Fig 18 -6 b ). In side th is dead bon e n ew osteon s are visible;
partially u n der orm ation , partially m atu re. In th e area o
lacu n ae ( Fig 18-5 ) th e so t-tissu e con ten t does n ot sh ow an y
sign s o in ection . Towards th e cen ter o th e m edu llary cavity
th ere is partially ch ron ic in f am m ation w ith m an y plasm a
cells an d local acu te in ection con tain in g sm all sequ estra
an d gran u locytes ( Fig 18-7 ). An in ection m em bran e su r-
rou n ds th e in tram edu llary abscess cavity.

1
2
2
b

Fig 18-5 Microradiography of an unde calci e d transve rse se ction of
the re m ove d cortical se gm e nt (se e Fig 18-3 ):
1 Laye r of ne wly form e d pe rioste al bone (se e also Fig 18 -6a ).
2 Are a of the original corte x. The de ad re m nants appe ar
com ple te ly white (se e also Fig 18 -6 b ). Most of the corte x
is re m ove d by oste oclastic activity, partially form ing e m pty
lacunae , partially be ing re place d by gray ne w bone form ation.
3 Location of Fig 18-7 .
Fig 18-6 a b Unde calci e d se ctions staine d according to
Romanowski.
a Ne w pe rioste al bone adjace nt to the de ad re m nants of the
original cortical bone ( 1 ). It contains num e rous channe ls
containing ve sse ls.
b Dead re mnants of the old corte x ( 2 ) with e mpty oste ocyte
hole s. The dead, brittle e le ments are fragmente d. Ne w vital
oste ons with central ve sse ls partially mature (le ft) partially in
formation pre senting a blue oste oid ring and oste oblasts lining it.

Fig 18 -7 De tail of the inne r lim it of the cortical are a (se e also Fig 18 -5 ).
Unde calci e d se ction, staine d according to Rom anowski. Num e rous
granulocyte s with se gm e nte d nucle i indicate an acute infe ction. One little
brittle se que strum with an attache d oste oclast containing two nucle i.

359
 Se ct io n 3Case s
18 Chronic
oste omye litis
of
the
tibia
5 Fu r t h e r d e ve lo p m e n t
An tibiotic treatm en t w ith am oxicillin / clavu lan ic acid 2.2 g
th ree tim es daily in traven ou sly w as con tin u ed or 6 w eeks,
ollow ed by 6 w eeks o oral treatm en t. C-reactive protein
w as < 5 m g/ L a ter 2 w eeks, ESR 8 m m / h a ter 3 m on th s.
Partial w eigh t bearin g w as ollow ed or 5 m on th s u sin g
cru tch es. Tw o w eeks later th e patien t slipped on ice an d
su ered a bon e ractu re rom th e bon e w in dow in a distal
direction n ecessitatin g a plaster cast or 6 w eeks. From th en
on th e patien t w as pain ree w ith ou t recu rren ce o in ection .
At th e 10-year ollow -u p, th e x-ray presen ted th icken ed
borders o th e bon e w in dow bu t n o closu re o th e gap
( Fig 18 -8 ). Tw en ty- ve years a ter th e treatm en t th e patien t
w as w ith ou t in f am m atory sym ptom s or pain .
a b c sequ estration s. A prim ary rem odelin g can occu r in
Fig 18-8 a c Postope rative de ve lopm e nt.
a X-ray at 3 m onths.
b X-ray take n 10 ye ars afte r ope rative re vision. Late ral cortical
window still visible . No re curre nce , no pain.
c Clinical photo take n 10 ye ars afte r ope rative re vision.
360
6 Co m m e n t
Th is osteom yelitis developed w ith ou t clear sign s o in ection ,
in itially even w ith ou t an y elevation o th e ESR. It is com -
preh en sible th at th e rst x-ray ( Fig 18-1 a ) su ggested a diag-
n osis o a m align an t bon e tu m ou r leadin g to a m agn etic
reson an ce im agin g su pportin g th is idea. A biopsy w ou ld
h ave been in dicated an d capable o revealin g th e correct
diagn osis. Becau se th e patien t re u sed a biopsy an d an y
th erapy, th e spon tan eou s developm en t cou ld be observed,
w h ich tu rn ed to an acu te abscess orm ation a ter 7.5 m on th s.
In th is period th e radiological pictu re becam e typical or
osteom yelitis w ith a clear-cu t extern al delim itation o th e
cortical th icken in g. An y orm ation o an in volu cru m or bu lky
sequ estru m w as m issin g con rm in g th e prim ary ch ron ic
developm en t.
7 Pit fa lls
In th e di eren tial diagn osis, a ch ron ic osteom yelitis
w as n ot in clu ded.
Th e cortical w in dow led to a very slow con solidation .
A slip on th e ice provoked a bon e ractu re. A better
tech n iqu e to cu t th e w in dow u sin g an oval h ole w ith a
rotary bu rr is advisable to avoid th is com plication
( Fig 17-6 ).
8 Pe a rls
Th e spon tan eou s developm en t o a prim ary ch ron ic
osteom yelitis in an adu lt can occu r w ith ou t exten ded
livin g bon e w ith periosteal n ew bon e orm ation an d
rem odelin g o th e earlier cortical area can occu r
spon tan eou sly.
Exception al spon tan eou s developm en t o a ch ron ic
osteom yelitis m im ickin g a m align an t tu m or can be
presen t w ith ou t an tibiotic th erapy.
9 Ack n o w le d ge m e n t s
Th e h istological section s w ere carried ou t by Peter Zim m er-
m an n in th e laboratory or u n decalci ed h istology ru n by
th e au th ors departm en t or orth opedic su rgery at th e
Kan ton sspital Liestal an d Stratec AG Oberdor , Sw itzerlan d.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Jong-Ke on Oh

19.1 Im p la n t re m o va lin fe cte d n o n u n io n o f th e

d is t a l h u m e ru s
Jon g-Ke o n Oh

1 Ca s e d e s crip t io n greater stability. Th e postoperative x-rays sh ow posterior

A 39-year-old m an in ju red h is righ t arm w h ile th row in g a
baseball 5 m on th s prior to visitin g th e au th ors clin ic. In -
ju ry lm s sh ow ed a low -en ergy spiral ractu re o th e distal
h u m eru s (AO/ OTA Classi cation 12-A1) ( Fig 19 .1-1 ). Closed
redu ction an d in tram edu llary n ailin g w as attem pted th e
day a ter in ju ry. Im m ediate postoperative x-rays sh ow ed
an u n su ccess u l attem pt at n ailin g. Mu ltiple-w edge ractu res
w ere iatrogen ically created du rin g th e n ailin g an d cerclage
w ires w ere u sed to x th e w edge ragm en ts ( Fig 19.1-2 ). A
secon d procedu re w as don e by th e sam e su rgeon 7 days
a ter in dex n ailin g, probably becau se it w as su spected th at
th e in itial n ailin g w as u n stable. Th is tim e th e n ail w as
rem oved an d posterior platin g w as per orm ed to ach ieve
platin g w ith a Y-plate ( Fig 19 .1-3 ). Accordin g to th e m edical
records, sw ellin g an d redn ess developed, ollow ed by dis-
ch arge rom th e su rgical w ou n d 2 w eeks a ter platin g (n o
ph otograph ic docu m en tation w as available). Th e organ ism s
iden ti ed by th e tissu e cu ltu re at th e tim e o debridem en t
w ere m eth icillin -resistan t Staphylococcus aureus (MRSA) an d
Enterobacter cloacae. Van com ycin was adm in istered in trave-
n ou sly on an d o du rin g th e cou rse o postoperative in ection
m an agem en t at th e previou s h ospital. Detailed in orm ation
abou t th e exact period o an tibiotic treatm en t rom th e su m -
m arized tran s er n ote w as n ot available. Th e prim ary su rgeon
per orm ed su rgical debridem en t twice with im plan t reten tion .
Th e patien t w as tran s erred to th e au th ors in stitu tion
4 m on th s later.

Fig 19 .1-3 Postope rative x-ray afte r re vision

Fig 19.1-1 Initial injury
x-ray shows low-e ne rgy
spiral fracture of the
distal hum e rus.
Fig 19.1-2 Postope rative x-ray shows an unsucce ssful
atte m pt at nailing. Multiple -we dge fracture s we re
iatroge nically cre ate d by nailing and ce rclage wiring was
use d re sulting in soft-tissue stripping.
surge ry pe rform e d 7 days afte r inde x nailing
showe d poste rior plating with a Y-plate . Lag
scre ws we re use d to x the we dge fracture s
and ce rclage wiring is also se e n at the proxim al
part of the fracture site . Give n the dire ction
of lag scre ws and the wiring, a circum fe re ntial
stripping of pe rioste um se e m s like ly. The le ngth
of the plate is too short with only two bicortical
scre ws place d into the proximal shaft.

361
 Se ct io n 3Case s
19.1Implant
removalinfe cte d
nonunion
of
the
distal
hume rus
Clin ical exam in ation sh ow ed a m idlin e scar alon g th e pos-
terior arm w ith good so t-tissu e coverage. A sm all drain in g
sin u s w ith pu ru len t disch arge w as n oted on th e lateral side
o th e distal arm . Th e elbow was sti with th e ran ge o m otion
rom 10, lackin g u ll exten sion to 100 o f exion . Wrist
drop w as n oted du e to com plete radial n erve palsy a ter th e
secon d su rgery (n ail rem oval an d platin g) by th e prim ary
su rgeon ( Fig 19 .1-4 ). X-rays sh ow resorption o bon e arou n d
th e ractu re m argin s arou n d th e cerclage w irin g an d screw
loosen in g. No sign s o ractu re h ealin g were visible ( Fig 19.1-5 ).
Blood tests w ere con du cted or screen in g an d eryth rocyte
sedim en tation rate (ESR) w as elevated to 50 m m / h (n orm al
ran ge: 010 m m / h ). C-reactive protein (CRP) level w as
sligh tly elevated to 5.8 m g/ L (n orm al ran ge: 05 m g/ L). All
oth er laboratory tests resu lts w ere w ith in th e n orm al ran ge.
a b
Fig 19.1-4a d Clinical photographs.
a The m idline scar along the poste rior
surface of the distal arm with good soft-
tissue cove rage . d a
b c Sm all draining sinus with pus discharge
was note d on the late ral side of the distal
arm (arrows).
d The patie nt's e lbow was stiff with the
range of m otion from 170 to 8 0 of
e xion. Wrist drop was note d due to
com ple te radial ne rve palsy (arrow).
362
2 In d ica t io n s
Based on th e h istory, th e diagn osis o an in ected n on u n ion
o th e distal h u m eral ractu re with radial n erve palsy an d
sti elbow join t w as m ade. In itial m an agem en t a ter postop-
erative in ection w as dictated by th e w ell-kn ow n orth opedic
prin ciple, th e so-called u n ion - rst strategy. Th e u n ion - rst
strategy in clu des operative debridem en t, an tibiotic su ppres-
sion , an d reten tion o h ardw are u n til ractu re u n ion occu rs.
Even a ter tw o attem pts o su rgical debridem en t an d an ti-
biotic su ppression , pu s drain age was persisten t. Mostly it did
n ot appear th at th e ractu re w as h ealin g based on tw o m ain
radiological n din gs:
1. Th e xation con stru ct did n ot a ord en ou gh stability
rom th e begin n in g, as th e plate len gth w as too sh ort
an d on ly tw o bicortical screw s w ere placed at th e
proxim al sh a t. Th e xation con stru ct at th is poin t
(4 m on th s postoperatively) w ith addition al screw
loosen in g is con sidered an u n stable con stru ct.
2. Th ere w ere n o radiograph ic sign s o ractu re h ealin g.
Th is represen ts a ailu re o th e u n ion - rst strategy an d
su rgical in terven tion in clu din g plate rem oval is
m an datory.
b
Fig 19.1-5a b X-rays show re sorption of bone
around the fracture m argins, e spe cially ne ar the
ce rclage wiring (white arrows) and scre w loose ning
( black arrows). No signs of fracture he aling we re
visible .
a AP vie w.
b Oblique vie w.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Jong-Ke on Oh

3 Pre o p e ra t ive p la n n in g 4 Su rgica l a p p ro a ch

Th e problem w as de n ed as an in ected n on u n ion o th e
distal h u m eral ractu re w ith radial n erve palsy. Th e au th or
plan n ed a staged recon stru ction . Local so t-tissu e con dition
w as good en ou gh or staged m u ltiple recon stru ction proce-
du res. Th e patien t w as h ealth y an d you n ga type A h ost.
Su rgical approach es w ere straigh t orw ard in th is case as
th ere w as a prior lon g posterior in cision ( Fig 19 .1-4 a ). It w as
plan n ed to split th e triceps m u scle all th e w ay u p to th e
spiral groove to locate th e radial n erve.

Stage 1: plate rem oval an d radical debridem en t o in ected 5 Su rgica l d e b rid e m e n t a n d im p la n t re m o va l

an d dead tissu e. Th e au th or plan n ed to ll th e bon e de ect
w ith an tibiotic-loaded polym eth ylm eth acrylate (PMMA)
cem en t spacer, as sign i can t bon e de ect a ter debridem en t
w as expected. Fou r gram s o van com ycin h ydroch loride
w ere m ixed w ith 40 g o PMMA bon e cem en t. Exploration
o th e radial n erve an d n eu rolysis, i possible, w as plan n ed.
Th e plan n ed exten t o bon e debridem en t w as based on th e
an alysis o previou s procedu res an d radiological n din gs.
Th e au th or th ou gh t th at w edge ractu res created by n ail
in sertion were m ost likely devitalized by wirin g an d lag-screw
placem en t in di eren t direction s en din g u p as sequ estru m .
Loosen in g o screw s an d bon e resorption arou n d th e w ires
w ere th e clu es or th is an alysis. It w as expected th at resec-
tion o th e bon e rom th e level o th e cerclage w ire dow n
to th e m ost distal lag screw on th e m edial side w ou ld be
per orm ed ( Fig 19.1-5 ). A tem porary bridgin g extern al xator
across th e elbow w as plan n ed to give stability. Th e procedu re
w as per orm ed in lateral position to u se th e previou s pos-
terior approach . Drapin g w as don e rom n gers to sh ou lder
an d a sterilized pn eu m atic tou rn iqu et w as plan n ed.
Stage 2: repeated debridem en t an d de n itive xation w ith
posterior platin g. Exch an ge th e PMMA cem en t spacer. Th e
su rgeon m ixed 40 g bon e cem en t w ith 4 g van com ycin h y-
droch loride based on th e previou s cu ltu re resu lts. Th e patien t
w as treated w ith 13.5 g piperacillin / tazobactam an d 3 g
van com ycin per day. Th e secon d-stage operation w as
plan n ed 23 w eeks a ter th e stage 1 procedu re as it w as
desirable to m obilize th e elbow as early as possible.
A lon gitu din al skin in cision w as m ade over th e previou s
operative scar. Th e plate w as exposed by th e triceps-splittin g
approach . All n ecrotic triceps m u scles in con tact w ith th e
plate w ere m eticu lou sly debrided. Th e plate w as covered
w ith in ected gran u lation tissu es an d pu s ( Fig 19.1-6a ). Th e
plate w as exposed m ore clearly by rem ovin g in ected gran -
u lation tissu es ( Fig 19 .1-6 b ). Th e plate w as taken ou t w ith ou t
di cu lty. Screw loosen in g w as n oted as expected based on
th e radiological n din gs. Plate rem oval exposed th e posterior
su r ace o th e distal h u m eru s ( Fig 19 .1-6 c ). Th ose previou s
w edge ragm en ts th at w ere expected to be devitalized an d
in ected w ere rem oved an d u rth er resection m argin s rom
th e proxim al an d distal ragm en ts w ere ch osen by th e capac-
ity to bleed at th e resection m argin s (Paprika sign ). Re-
m oval o w edge ragm en ts w as con irm ed w ith im age
in ten si cation ( Fig 19.1-7 ). An in traoperative clin ical ph oto
sh ow s th e plate an d dead bon e ragm en ts th at w ere rem oved
( Fig 19 .1-8 ).
Th e radial n erve w as iden ti ed at th e spiral groove an d
in tact con tin u ity w as veri ed ( Fig 19 .1-9 ). Neu rolysis w as
per orm ed by rem ovin g scar tissu e arou n d th e n erve.

Stage 3: polym eth ylm eth acrylate cem en t spacer rem oval
an d au togen ou s bon e gra t. Th is n al stage procedu re w as
plan n ed or 34 m on th s a ter th e secon d-stage procedu re.
Mean wh ile aggressive reh abilitation to restore th e elbow-join t
m otion an d m on th ly ollow -u p w ith clin ical exam in ation
w ere plan n ed to en su re th at th e ESR/ CRP levels h ad n or-
m alized be ore th e bon e gra t an d w ith ou t clin ical sign s o
recu rren t in ection . System ic an tibiotics th erapy: 13.5 g
piperacillin / tazobactam an d 3 g van com ycin per day w ere
in trodu ced or 6 w eeks a ter su rgery.

363
 Se ct io n 3Case s
19.1Implant
removalinfe cte d
nonunion
of
the
distal
hume rus

a b c
Fig 19.1-6a c Intraope rative photographs.
a Infe cte d granulation tissue and pus cove ring the plate afte r a trice ps-split approach.
b The plate is m ore cle arly e xpose d afte r de bride m e nt of surrounding infe cte d tissue s.
c Plate re m oval e xpose d de ad cortical bone surface with m ultiple scre w hole s, som e of which are
e nlarge d due to re sorption around the loose ne d scre ws. Note also cle arly visible nonunion gaps. Scre w
hole s and nonunion gaps containe d infe cte d granulation tissue s.

a b
Fig 19.1-7a b Intraope rative im age s. Fig 19 .1-8 Re m ove d de ad bone fragm e nts
a Im age take n afte r de ad bone re se ction. and the plate .
b C-arm im age shows the size of the bone de fe ct afte r
de bride m e nt.

Fig 19 .1-9 Intraope rative

photograph shows the radial
ne rve ide nti e d at the radial
groove (arrow).

364 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jong-Ke on Oh

6 Te m p o ra r y fixa t io n 7 Po s t o p e ra t ive m a n a ge m e n t

Th e bon e de ect w as th en tem porarily lled w ith an an tibi-
otic-loaded (4 g o van com ycin in 40 g o PMMA pow der)
PMMA cem en t spacer ( Fig 19.1-10 ). A f exible n ail w as in tro-
du ced in to th e m edu llary can al to h elp stabilize th e cem en t
spacer w ith in th e de ect. An in du ced m em bran e w ill orm
arou n d th e cem en t spacer an d in tu rn th e gra ted bon e w ill
be con tain ed by th e in du ced m em bran e at th e th ird-stage
procedu re. Th e spacer w as sh aped sim ilar to th e n orm al
bon e m orph ology at th at level.
Postoperatively th e arm w as kept in a com ortable position ,
passive w rist an d n ger exten sion an d active f exion exer-
cises w ere per orm ed w ith u n ction al bracin g to reh abilitate
th e radial n erve palsy. Van com ycin w as in u sed in trave-
n ou sly or 3 w eeks a ter debridem en t. In traoperative tissu e
cu ltu re revealed MRSA as th e cu rren t in ectin g organ ism
w h ich con rm ed th e previou s cu ltu re.

Tem porary stabilization w as n ecessary to m ain tain stability.

A bridgin g extern al xator w as applied across th e elbow
join t. Th e position s o proxim al Sch an z screw s w ere ch osen
n ot to h in der th e de n itive plate xation at th e secon d-stage
procedu re ( Fig 19.1-11 ).

Fig 19.1-10 Afte r bone re se ction the
de fe ct was lle d with vancomycin-
loade d polyme thylm e thacrylate
ce m e nt spacer.
a b c
Fig 19 .1-11a c Postope rative im age s.
a b X-rays show the size of the bone de fe ct that is lle d with
polym e thylm e thacrylate ce m e nt space r. Note the bridging e xte rnal
xator. A e xible nail was use d to he lp stabilize the ce m e nt space r.
c The longitudinal surgical wound and bridging e xte rnal xator.

365
 Se ct io n 3Case s
19.1Implant
removalinfe cte d
nonunion
of
the
distal
hume rus

8 Re im p la n t a t io n o su rrou n din g so t tissu es w ere m eticu lou sly trim m ed o

8 .1 Se co n d -s t a ge p ro ce d u re
Th ree w eeks a ter th e rst-stage debridem en t an d tem porary
extern al xation , th e su rgical w ou n d w as clin ically clean
an d pu ru len t drain age th rou gh th e sin u s tract h ad stopped
ollow in g th e in itial debridem en t. Th e secon d-stage proce-
du re w as per orm ed as plan n ed. Th e extern al xator w as
kept to m ain tain th e len gth . Th e PMMA cem en t spacer w as
exposed by splittin g th e triceps again . Previou s bon e resec-
tion m argin s w ere care u lly exam in ed again an d u rth er
resection w as per orm ed du e to lack o bleedin g at th e cor-
tical m argin o th e proxim al ragm en t ( Fig 19.1-12 ). Margin s
again . Trim m ed tissu es w ere prepared or an oth er tissu e
cu ltu re. Th en de n itive xation w as carried ou t u sin g an
extraarticu lar lockin g com pression plate distal h u m eru s
(LCP-DH). Addition al platin g w as don e alon g th e m edial
side o th e h u m eru s across th e bon e de ect. Th en th e bon e
de ect w as lled w ith an an tibiotic-loaded PMMA cem en t
spacer. On ce th e xation w as com plete, th e u ll ran ge o
elbow join t m otion cou ld be con rm ed ( Fig 19 .1-13 ). Th e
w ou n d w as closed over a su ction drain age. In traven ou s
van com ycin w as prescribed or 2 w eeks. Su ction drain age
w as rem oved 3 days a ter platin g, ollow ed by aggressive
ran ge-o -m otion exercises.

a b
Fig 19.1-12 Intraope rative image shows the
bone de fe ct afte r ce m e nt re m oval.

c d
Fig 19 .1-13a d Intraope rative im age s.
a Poste rior plating along the late ral colum n. The white arrow indicate s the radial
ne rve unde r which the plate was slid. Additional plating ( black arrow) at right angle s
to the poste rior plate was pe rform e d along the m e dial side of the distal hum e rus.
b Bone de fe ct was lle d with a polym e thylm e thacrylate ce m e nt space r (white arrow).
c d Intraope rative e lbow joint m otion afte r xation and ce m e nt space r inse rtion.

366 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jong-Ke on Oh
Postoperative x-rays sh ow a du al platin g con stru ct w h ich
w as stable en ou gh to com m en ce vigorou s reh abilitation 4
days postoperatively wh en th e drain was rem oved ( Fig 19.1-14 ).
Th e au th or ollowed u p th e patien t with m on th ly laboratory
tests an d x-rays or 4 m on th s postoperatively to en su re th at
th e ESR/ CRP levels n orm alized 4 w eeks a ter th e secon d-
stage de n itive xation an d stayed at th e n orm al level or
an oth er 3 m on th s. Th e patien t w as treated in traven ou sly
w ith piperacillin / tazobactam 3 x 4.5 g an d van com ycin 3
x1 g per day or 6 w eeks a ter su rgery. No addition al oral
an tibiotics w ere given becau se th e serological m arker w as
n orm alized a ter treatm en t w ith in traven ou s an tibiotics.
Th ere w ere n o sign s o recu rren ce o in ection du rin g th is
Fig 19.1-14 a b Postope rative
x-rays show a dual plating
construct.
a AP vie w.
a b b Late ral vie w.
a b
Fig 19.1-16a c Intraope rative photographs.
a The ce m e nt space r with cle an surrounding soft tissue s.
b Whitish-induce d m e m brane (arrow) is visible afte r ce m e nt space r re m oval.
c Cance llous bone graft lling the de fe ct.
period. Th e ESR an d CRP levels w ere n orm alized. Th e patien t
regain ed elbow join t m otion w ith 15 o f exion con tractu re
an d 95 o f exion by th is tim e ( Fig 19 .1-15 ). Radial n erve
palsy also u lly recovered spon tan eou sly.
8 .2 Th ird -s t a ge p ro ce d u re
Th e sam e posterior approach w as u sed to expose th e cem en t
spacer. A sm all am ou n t o serou s f u id collection w as n oted
arou n d th e cem en t. Oth er th an th at tissu es w ere clean an d
n o gross eviden ce o in ection w as ou n d. Th e cem en t spac-
er w as rem oved w ith th e u se o a cem en t-rem ovin g ch isel.
Wh itish -in du ced m em bran e w as w ell orm ed arou n d th e
cem en t spacer ( Fig 19.1-16 ).
b
Fig 19.1-15a b Four m onths afte r se cond-stage plating the re
is re storation of elbow joint m otion without signs of infe ction.
a Fle xion.
b Exte nsion.
c
367
 Se ct io n 3Case s
19.1Implant
removalinfe cte d
nonunion
of
the
distal
hume rus
Th e bon e de ect w as lled w ith au togen ou s can cellou s bon e
gra t taken rom th e ipsilateral iliac crest ( Fig 19.1-17a ).
Th e su rgical w ou n d w as closed over a su ction drain . Post-
operative x-rays taken im m ediately a ter bon e gra t sh ow
gra ted bon e sh adow alon g th e m edial colu m n ( Fig 19 .1-17 ).
Fig 19.1-17a b
Postope rative x-rays show
grafte d bone that re place d
the ce m e nt space r
(arrows).
a AP vie w.
a b b Late ral vie w.
a b
Fig 19 .1-18 a d Follow-up im age s
6 m onths afte r bone graft.
a b X-rays show consolidation of
grafte d bone (arrows).
c d Range of m otion of the right
e lbow without any signs of
c infe ction.
368
9 Ou t co m e
On postoperative day 4, th e drain w as rem oved. Active ran ge
o m otion w as en cou raged a ter th is poin t. X-rays taken 6
m on th s a ter bon e gra tin g dem on strate con solidation an d
corticalization o th e gra ted bon e. Th e patien t recovered
n early u ll ran ge o h is elbow join t m otion ( Fig 19.1-18 ).
10 Pit fa lls
Th e u n ion - rst strategy or th e m an agem en t o acu te
postoperative in ection a ter ractu re xation in clu des
operative debridem en t, an tibiotic su ppression , an d
reten tion o h ardw are u n til ractu re u n ion occu rs. Th is
strategy w orks on ly w h en th ere is reason able eviden ce
or ractu re h ealin g w h ile in ection is bein g su ppressed.
It is n ot likely to su cceed in th e presen ce o a m u lti-
dru g-resistan t organ ism like MRSA.
I th ere are n o radiological sign s o progressive ractu re
h ealin g or th e stability is n ot su cien t, rem ove th e
h ardw are an d per orm staged ractu re xation an d
bon e recon stru ction a ter radical debridem en t.
11 Pe a rls
It is critical to h ave a plan or th e w h ole staged
recon stru ction be ore com m en cin g treatm en t. It is also
im portan t to in orm th e patien t an d h is or h er am ily
abou t th e treatm en t plan an d possible com plication s
an d problem s th at m ay alter th e su rgeon s plan s.
Regardin g th e xation con stru ct, it is vital to con sider a
postoperative reh abilitation plan . In th is case th e
patien t presen ted w ith in ected n on u n ion an d a sti
elbow .
An aggressive reh abilitation a ter de n itive xation at
th e secon d-stage procedu re w as plan n ed. It took lon ger
th an expected or u n ion a ter bon e gra tin g, th ere ore,
a du al platin g con stru ct w as ch osen th at w as th e
stron gest xation option available.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Jong-Ke on Oh

19.2 Im p la n t re m o va lin fe cte d n o n u n io n o f th e tib ia

Jon g-Ke o n Oh

1 Ca s e d e s crip t io n w as n ot available. Follow -u p x-rays taken 7 m on th s a ter

A 66-year-old m an in ju red h is righ t leg in a tra c acciden t
17 m on th s prior to visitin g th e au th ors clin ic. In ju ry lm s
dem on strated a h igh -en ergy open diaph yseal ractu re o th e
distal tibia (AO/ OTA Classi cation 42-C) ( Fig 19.2-1 ). Ph o-
tograph ic docu m en tation o th e in itial w ou n d w as n ot
available. Open redu ction an d in tram edu llary n ailin g w as
don e prim arily a ter debridem en t ( Fig 19 .2 -2 ). Th e open
w ou n d w as closed prim arily an d in orm ation abou t th e
exact so t-tissu e con dition be ore an d a ter debridem en t
th e in dex operation sh ow th e rem oval o a proxim al in ter-
lockin g screw du e to loosen in g an d n o callu s orm ation at
eith er th e proxim al or distal ractu re sites ( Fig 19.2 -3 ). Ac-
cordin g to th e m edical records, at th is tim e th ere w as deep
in ection at th e distal ractu re site w ith pu ru len t disch arge.
Th e cau sative organ ism w as Escherichia coli by tissu e cu ltu re.
A secon d operation w as per orm ed by th e prim ary su rgeon
to con trol th e in ection . Th ere w as segm en tal resection
arou n d th e distal ractu re site an d recon stru ction o th e
de ect by bon e tran sport tech n iqu e w ith th e u se o an Ilizarov

a b
Fig 19.2-1a b Initial x-rays show high-energy
diaphyse al fracture of the right tibia.
a AP vie w.
b Late ral vie w.
a b
Fig 19 .2 -2 a b Postope rative x-rays take n
imme diate ly afte r the inde x ope ration show
ope n re duction and ce rclage wiring around
both the proximal and distal fracture site s
and nailing. This construct doe s not appe ar
stable e spe cially at the proximal fracture
site as only one inte rlocking scre w was
use d to stabilize the proximal fragme nt.
a AP vie w.
b Late ral vie w.
a b
Fig 19 .2 -3a b Follow-up x-rays
take n 7 m onths afte r inde x ope ration
de m onstrate re m oval of the proxim al
inte rlocking scre w due to loose ning
and no callus formation at e ithe r the
proxim al or distal fracture site s.
a AP vie w.
b Late ral vie w.

369
 Se ct io n 3Case s
19.2Implant
removalinfe cte d
nonunion
of
the
tibia

rin g ram e ( Fig 19 .2 -4 ). Th e Ilizarov ram e w as rem oved 2 In d ica t io n s

9 m on th s a ter osteotom y. Th e patien t w as tran s erred to
th e au th ors clin ic 1 m on th a ter ram e rem oval. X-rays Th e patien t h ad dou ble-level m alalign m en t (10 o valgu s
(17 m on th s a ter in ju ry) sh ow dou ble-level m alalign m en t at th e proxim al regen erate bon e colu m n an d 15 o varu s
(10 valgu s at th e proxim al regen erate bon e colu m n an d at th e distal dockin g site) w ith 17 m m sh orten in g. Distal
15 varu s at th e site o th e distal dockin g site) w ith 17 m m dockin g-site u n ion w as in com plete, so an addition al su rgi-
sh orten in g. Bridgin g callu s orm ation alon g th e m edial cor- cal procedu re w as requ ired to correct th e de orm ity an d to
tex w as n ot visible at th e distal dockin g site w ith a visible ach ieve solid u n ion .
ractu re gap ( Fig 19 .2 -5 ). Th ere w as ten dern ess over th e
distal n on u n ion site. Th e w ou n d w as covered w ell an d th ere
w ere n o clin ical sym ptom s an d sign s o in ection or th e past
9 m on th s. Th e an kle w as sti w ith m in im al m otion presen t
( Fig 19 .2 -6 ). Blood tests sh ow ed th e eryth rocyte sedim en ta-
tion rate (ESR) w as elevated to 35 m m / h (n orm al ran ge:
010 m m / h ). Oth er th an th at every laboratory test w as
w ith in n orm al ran ge in clu din g th e C-reactive protein (CRP)
level at 1.20 m g/ L (n orm al ran ge: 05 m g/ L).

Fig 19.2-4 Se gm e ntal
re se ction around the distal
fracture site and bone
transport with an Ilizarov
fram e was pe rform e d
9 m onths afte r injury.
a b c a b
Fig 19 .2 -5a c X-rays take n 1 m onth afte r fram e re m oval show Fig 19 .2 -6 a b Clinical photographs
double -le ve l malalignm e nt (10 valgus at the proxim al re ge ne rate just be fore corre ction and nailing. The
bone colum n and 15 varus malalignm e nt pre se nt at the distal wound was cove re d we ll and the re
docking site) with 17 m m of shorte ning. Bridging callus form ation we re no clinical sym ptoms and signs
along the m e dial corte x was not visible at the distal docking site of infe ction for the past 9 m onths.
with a visible fracture gap pre se nt.
a AP vie w.
b Late ral vie w.
c Orthoradiogram vie w for com parative alignm e nt.

370 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jong-Ke on Oh
3 Pre o p e ra t ive p la n n in g
Con siderin g th e patien ts age, sti an kle, an d som e expected
len gth restoration a ter realign m en t, len gth en in g w as n ot
in corporated in to th e su rgical plan n in g. Acu te correction
w ith dou ble-level osteotom y an d n ailin g plu s au togen ou s
bon e gra t at th e osteotom y sites w as plan n ed ( Fig 19 .2 -7 ).
Alth ou gh th e ESR level w as elevated, th e au th or did n ot
speci cally plan or m an agem en t o in dolen t in ection as
th e patien t h ad n ot sh ow n an y clin ical sign s o in ection or
th e past 9 m on th s. In traoperative n eu troph il cou n t w as
plan n ed to be u sed as a gu ide or possible bu t less likely
staged operation s, m ean in g debridem en t an d tem porary
extern al xation an d polym eth ylm eth acrylate (PMMA)
cem en t spacer ollow ed by secon d-stage recon stru ction . Th e
patien t w as position ed su pin e w ith th e u se o pn eu m atic
Fig 19 .2 -7 Double -le ve l oste otom ie s
ce nte re d ove r the ce nte r of rotation
axe s 1 and 2 we re planne d.
tou rn iqu et. It w as believed th at th e em oral distractor m ay
n ot be h elp u l as th e bon e qu ality w as poor du e to disu se
osteoporosis resu ltin g rom th e prolon ged period o n on -
w eigh t bearin g. In stead it w as plan n ed to n avigate a h an d
ream er th rou gh th e cen tral axes o th e th ree m ain ragm en ts
a ter dou ble-level osteotom y (So eld osteotom y). A bu lar
osteotom y w as plan n ed on ly i th e am ou n t o de orm in g
orces w ere big en ou gh to h in der correction o tibial de or-
m ities.
4 Su rgica l a p p ro a ch
Su rgical approach es w ere straigh t orw ard in th is case as
th ere w ere dou ble-level de orm ities an d th e skin con dition
w as acceptable to m ake lon gitu din al in cision s directly over
th e an terior su r ace o th e tibial crest ( Fig 19 .2 -8 ).
a b
Fig 19.2-8 a b Dire ct longitudinal skin incisions
we re m ade ove r the oste otomy site s.
371
 Se ct io n 3Case s
19.2Implant
removalinfe cte d
nonunion
of
the
tibia

5 Su rgica l d e b rid e m e n t 7 Ou t co m e

Upon open in g th e proxim al m alu n ion an d distal n on u n ion
sites, th ere w ere n o clin ical sign s o in ection . In traoperative
polym orph on u cleocyte cou n ts rom both sites sh ow ed less
th an 1 per h igh -pow er eld. Debridem en t w as per orm ed
to rem ove th e sclerotic bon es arou n d th e osteotom y sites
u n til h ealth y bon e w as exposed. In traoperative ph otos w ere
taken a ter debridem en t an d n ailin g an d sh ow th e size o
th e de ects at both levels ( Fig 19 .2 -9 ). Th ese de ects w ere
lled w ith au togen ou s can cellou s bon e rom th e iliac crest.
6 Po s t o p e ra t ive m a n a ge m e n t
Postoperatively th e leg w as elevated w ith tem porary im -
m obilization in a lon g leg splin t. In traven ou s in u sion o
rst-gen eration ceph alosporin w as prescribed accordin g to
th e rou tin e protocol or an elective clean su rgery.
Postoperative x-rays sh ow correction o align m en t an d
statically locked n ailin g ( Fig 19.2-10 ).
On postoperative day 3, th e drain w as rem oved as th e am ou n t
o drain age dim in ish ed to 7 m L/ day. On postoperative day
4, th e tissu e cu ltu re rom th e proxim al osteotom y site grew
E coli. On postoperative day 5, th e patien t developed a spik-
in g ever o 38.5 C an d th e drain tip cu ltu re revealed E coli.
In respon se to th is situ ation , an tibiotics w ere started w ith
-lactam ase in h ibitor based on th e cu ltu re resu lts. Th e ever
w as n ot con trolled even a ter an tibiotic ch an ge bu t th e su r-
gical debridem en t w as delayed m ain ly du e to th e su rgeon s
relu ctan ce to ace th e reality o in ection a ter su ccess u l
recon stru ctive procedu re in clu din g au togen ou s bon e gra t.
Fin ally, a decision or su rgical debridem en t w as m ade on
postoperative day 9 w h en pu ru len t disch arge th rou gh th e
proxim al su rgical w ou n d w as n oted ( Fig 19 .2 -11 ).

a b
Fig 19.2-9 a b Intraope rative photographs afte r
de bride m e nt and nailing show the size of the
de fe cts at both le ve ls
( proximal: white arrow, distal: black arrow).
a b
Fig 19.2-10 a b Postope rative
x-rays show corre ction of
alignm e nt and statically locke d
nailing.
a b
Fig 19.2-11a b Photographs 9 days afte r
re construction.
a Note swe lling and re dne ss around the
proxim al oste otom y site (circle).
b A close -up vie w shows purule nt discharge
from the focal sinus tract just m e dial to the
m ain surgical wound (arrow).

372 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jong-Ke on Oh

8 Pre o p e ra t ive p la n n in g 9 Su rgica l a p p ro a ch

Both th e in traoperative tissu e cu ltu re an d th e drain tip cu ltu re
iden tically revealed E coli th at w as th e in ectin g organ ism ;
th is w as iden tical to th e in ection a ter in itial in ju ry. Th e
diagn osis is reactivation o an in dolen t in ection . It also
carries all eatu res o acu te deep postoperative in ection . It
is critical to h ave a roadm ap or th e w h ole treatm en t process
th at o ten in clu des m u ltiple plan n ed procedu res. Th is patien t
n ow h ad seriou s postoperative deep in ection w ith dou ble-
level n on u n ion w ith sign i ican t bon e de ect. All th ese
problem s can n ot be solved by a sin gle su rgical procedu re.
A com preh en sive treatm en t roadm ap is n eeded to en su re
th e su ccess o treatm en t.
First stage: u rgen t su rgical debridem en t
1. Su rgical debridem en t in clu din g all th e bon e gra t.
2. Extern al xation alon g th e m edial side to m ain tain
align m en t. Sch an z screw placem en t m u st n ot h in der
repeated n ailin g at th e secon d stage.
3. Nail rem oval, ream in g o th e m edu llary can al.
4. In sertion o an tibiotic-loaded PMMA bead ch ain w ith in
th e m edu llary can al, addition al PMMA cem en t spacer
at th e de ect.
5. Prim ary w ou n d closu re over a drain or tem porary
w ou n d coverage w ith n egative-pressu re w ou n d
th erapy (NPWT) closu re.
Previou s in cision s w ere u sed to per orm debridem en t an d
im plan t rem oval.
10 Su rgica l d e b rid e m e n t
Upon open in g th e proxim al osteotom y site, pu s w as ou n d
an d sign i can t n ecrosis o th e m edial gastrocn em iu s an d
soleu s m u scles origin s arou n d th e proxim al osteotom y site
( Fig 19.2-12 ). Based on th is n din g th e au th or decided to
rem ove th e n ail or a th orou gh an d radical debridem en t.
Th ere w as bloody pu s arou n d th e proxim al an d distal in ter-
lockin g screw h oles. All th e bon e gra t at both osteotom y
sites w as com pletely rem oved an d th e in terlockin g screw
h oles w ere cu retted. Th e m edu llary can al w as ream ed to
debride th e in ected gran u lation tissu e rom th e m edu llary
can al. Ream in g th e proxim al m etaph ysis is n ot as e cien t
as ream in g th e diaph yseal area becau se th e m edu llary can al
is w ide. Addition al cu rettage w as per orm ed to u rth er
debride th e proxim al m edu llary can al.

Secon d stage: secon d debridem en t an d de in itive xation

1. Per orm ed 23 w eeks a ter rst-stage procedu re.

2. Repeated debridem en t.
3. Repeated n ailin g an d cem en t spacer at th e bon e de ect
over th e tw o osteotom y sites.

Th ird stage: bon e gra t (Masqu elet or in du ced-m em bran e

tech n iqu e)

1. A ter 34 m on th s clin ical observation or an y sign s o

recu rren ce o in ection . Fig 19.2-12 Intraope rative photograph shows the ne crotic tissue s
2. Serial m on th ly laboratory testin g or ESR/ CRP levels. re m ove d around the proxim al oste otomy site (circle).
3. Wh en th ere are n o clin ical sign s o in ection an d a
n orm alized ESR/ CRP level, rem ove cem en t spacer
rom th e de ect an d au togen ou s bon e gra t.

373
 Se ct io n 3Case s
19.2Implant
removalinfe cte d
nonunion
of
the
tibia

Upon com pletion o th e debridem en t th e m edu llary can al 12 Te m p o ra r y fixa t io n

w as lled w ith an an tibiotic-loaded PMMA cem en t bead
ch ain an d a cem en t spacer w as placed to ll th e bon y de ect
an d so t-tissu e de ect at th e proxim al w ou n d ( Fig 19 .2 -13 )
Both th e in cision or n ail en try an d th e distal osteotom y
sites (w h ite arrow s) w ere closed prim arily w ith ou t ten sion .
Th e w ou n d at th e proxim al osteotom y site (black arrow )
w as le t open w ith NPWT du e to ten sion u pon trial closu re.
Th e n egative pressu re w as kept at th e low est level o 25 m m
Hg in an in term itten t m ode to try to m ain tain th e local
con cen tration o an tibiotic release as h igh as possible.
11 Im p la n t re m o va l
Align m en t w as m ain tain ed w ith tem porary extern al xation
alon g th e m edial side be ore th e n ail was rem oved ( Fig 19.2-13 ).
On e Sch an z screw w as u sed in each ragm en t as th e h ealed
bu la acted as a stru t on th e oth er side.
13 Po s t o p e ra t ive m a n a ge m e n t
Postoperatively, a lon g leg split was u sed to add stability to
th e de ect sites. Th e NPWT dressin g w as ch an ged every 3
days in th e operatin g room w ith th e patien t u n der local
an esth esia.

Align m en t w as m ain tain ed w ith an extern al xator alon g

th e m edial side. An d as revision n ailin g w as plan n ed at th e
secon d-stage operation in th e roadm ap, th e Sch an z screw s
w ere placed aw ay rom th e n ailin g path ( Fig 19 .2 -14 ). Th e
origin al n ail w as rem oved th rou gh th e previou s in cision
on ce th e extern al xator w as in place.

a b c b c
Fig 19.2-13a c Intraope rative image s. Fig 19.2-14a c Intraope rative C-arm im age s (a -b ) and photograph
a The status of the soft tissue s be fore wounds closure . Through (c ) take n afte r Schanz scre w place m e nt. Note the position of the
the m iddle wound ( black arrow) polym e thylm e thacrylate Schanz scre ws (arrows) which will not inte rfe re with nailing that was
ce m e nt space rs are visible which we re place d into the bone planne d as a se cond-stage proce dure afte r control of the infe ction.
de fe ct and de ad space around the m e dial origin of the
gastrocne m ius and sole us muscle s group.
b AP x-ray vie w.
c Late ral x-ray vie w.

374 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jong-Ke on Oh

14 Re im p la n t a t io n Devitalized gastrocn em iu s m u scle tissu e w as u rth er de-

w as taken 3 days a ter th e rst-stage debridem en t
Fig 19.2 -15
an d sh ow s th e so t-tissu e de ect arou n d th e proxim al oste-
otom y site. At th is poin t th e au th or decided to add a ree
f ap as part o th e secon d-stage operation .
Th e secon d-stage operation w as per orm ed 2 w eeks a ter
th e rst-stage debridem en t. Th e PMMA bead ch ain an d spac-
ers w ere rem oved an d all su rgical sites w ere debrided again .
brided ( Fig 19.2-16 ). Su rgeon s th en ch an ged su rgical gow n s
an d drapin g be ore proceedin g to revision n ailin g. Nailin g
w as don e an d de ects w ere again lled w ith PMMA spacers
( Fig 19 .2 -17 ). A ter revision n ailin g, th e patien t w as allow ed
to partially bear w eigh t as tolerated on ce th e an terolateral
th igh per orator f ap w as stabilized. Postoperative x-rays
sh ow acceptable coron al plan e align m en t w ith 2.5 cm sh ort-
en in g. An apex an terior an gu lation at th e proxim al oste-
otom y site w as n oted ( Fig 19 .2 -18 ).

a b c
Fig 19.2-15 Clinical photograph 3 days afte r Fig 19.2-16a c Intraope rative se cond-stage photographs.
the rst-stage ope ration shows a soft-tissue a b Discolore d m e dial origin of gastrocne m ius muscle (circle and arrow).
de fe ct around the proxim al oste otom y site . c All ne crotic m uscle tissue was de bride d.

a b c a b c
Fig 19.2-17 a c Intraope rative ( a b ) and postope rative (c ) photographs. Fig 19.2-18a c Postope rative x-rays show acce ptable
a The e xpose d nail due to bone de fe cts on both oste otomy site s coronal plane alignm e nt with 2 .5 cm shorte ning. Ape x ante rior
(white arrows). The aste risk indicate s the de ad space le ft afte r angulation at the proxim al oste otom y site is note d.
de bride m e nt of ne crotic m uscle . a AP vie w.
b Bone de fe cts and the de ad space we re lle d with b Late ral vie w.
polym e thylm e thacrylate ce m e nt space rs. c Full le g-le ngth vie w.
c The skin de fe ct was re constructe d with an ante rolate ral thigh
pe rforator ap by a plastic surge on.

375
 Se ct io n 3Case s
19.2Implant
removalinfe cte d
nonunion
of
the
tibia

Th e th ird-stage operation w as per orm ed 18 w eeks a ter th e
secon d-stage operation .
Du rin g m on th ly ollow -u p, th ere w as n o sign o in ection
recu rren ce an d th e CRP level w as n orm alized. Th e ESR w as
m oderately elevated in con trast to th e clin ical n din gs an d
CRP level at th is poin t. As th ere w as n o detectable reason
or th is m oderately elevated ESR level, th e au th or decided
to per orm a bon e gra t. Th e cem en t spacers w ere rem oved
rom th e bon e de ects an d th e de ects w ere illed w ith
au togen ou s can cellou s bon e gra t rom th e iliac crest. For
th e proxim al osteotom y site, au gm en tation platin g w as don e
w ith a variable an gle lockin g plate 2.7 ( Fig 19.2-19 ). Post-
operative x-rays sh ow th e gra ted bon e colu m n ( Fig 19.2-20 ).
Th e patien t w as given in traven ou s an tibiotics sen sitive to
E coli or 2 w eeks. Alth ou gh it w as believed th e in ection
w as com pletely con trolled, in traven ou s an tibiotics w ere
prescribed to preven t recu rren ce o in ection .

a b c d
Fig 19.2-19 a d Intraope rative photographs.
a b The e xte nt of the proxim al bone de fe ct (thick white arrow) afte r polym e thylm e thacrylate ce m e nt space r re m oval. Also note
the locking plate 2 .7 for augm e ntation (thin white arrow). This de fe ct was lle d with autoge nous cance llous bone graft
( black arrow).
cd The white arrow indicate s the distal bone de fe ct around the nail and the black arrow indicate s the grafte d bone that lls
the de fe ct.

Fig 19 .2 -20a b Postope rative x-rays show the

grafte d bone colum n (arrows).
a AP vie w.
a b b Late ral vie w.

376 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Jong-Ke on Oh

15 Ou t co m e

X-rays taken 6 m on th s a ter bon e gra t dem on strate good

ractu re h ealin g w ith circu m eren tial rem odelin g o th e
gra ted bon e colu m n s at both levels ( Fig 19 .2 -21 ). Th ere w ere
n o sign s o recu rren ce o in ection at th is poin t. Th e patien t
w as able to w alk w ith ou t su pport. He h ad som e lim pin g du e
to 2 cm sh orten in g an d sti n ess o th e an kle join t.

a b c
Fig 19.2-21a c Six m onths afte r the third-stage ope ration ( bone graft).
a b AP ( a ) and late ral ( b ) x-rays show com ple te fracture he aling and
re m ode ling of grafte d bone columns.
c Clinical photograph shows the status of the soft tissue at this tim e .

377
 Se ct io n 3Case s
19.2Implant
removalinfe cte d
nonunion
of
the
tibia

16 Pit fa lls 17 Pe a rls

In th is case th e in itial diagn osis w as in dolen t in ection Con sider in dolen t in ection i :
w ith m alalign m en t. An in itial h igh -en ergy open Th e h igh -en ergy in ju ry is in itially n ot m an aged
ractu re w ith a h istory o in ection a ter poor in itial accordin g to accepted prin ciples.
m an agem en t, prolon ged period o extern al xation , Th ere is h istory o m u ltiple su rgical procedu res an d
an d elevated ESR. All th ese n din gs su ggested th e in ection .
possibility o an in dolen t in ection even in th e absen ce Th ere is elevated ESR/ CRP levels.
o clin ical sign s o in ection . Th e rst reaction to th e postoperative in ection is n ot
In traoperative polym orph on u clear cou n ts can n ot be em piric th erapy w ith an tibiotics bu t an u rgen t su rgical
u sed as a reliable in dicator o th e presen ce o in ection . debridem en t.
Acu te postoperative in ection (reactivation o in dolen t Th e en tire treatm en t roadm ap h as to be set u p in clu d-
in ection in th is case) requ ires an u rgen t su rgical in g all th e staged de n itive xation s an d, i n ecessary,
debridem en t. In th is case, on postoperative day 4, th ird-stage bon e gra t at th e tim e o rst-stage su rgical
w h en th e in traoperative tissu e cu ltu re revealed E coli debridem en t.
an d ever, th e su rgeon sh ou ld h ave per orm ed an
u rgen t su rgical debridem en t. In itial decision m akin g
w as to ch an ge an tibiotic th erapy. Th e su rgical debride-
m en t w as delayed sign i can tly u n til postoperative day
9 w h en th ere w as a pu ru len t disch arge rom th e
su rgical w ou n d. Th is delay critically w orsen ed th e
situ ation by givin g th e bacteria an opportu n ity to
destroy bon e an d so t tissu es. As a resu lt o delay in
debridem en t, th e exten t o debridem en t w as sign i -
can tly in creased so th at th e ree f ap w as n ecessary to
cover th e so t-tissu e de ect a ter debridem en t.

378 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Olivie r Bore ns

19.3 Im p la n t re m o va lch ro n ica lly in fe cte d to t a l h ip

a rth ro p la s t y
Olivie r Bo re ns

1 Ca s e d e s crip t io n cu p to preven t u rth er dislocation s. Delayed h ealin g o th e

A 63-year-old m an u n derw en t total h ip arth roplasty (THA)
or sym ptom atic arth ritis o th e righ t h ip 2 years prior to
presen tation at th e au th ors h ospital ( Fig 19.3 -1 ).
Tw o w eeks a ter th e origin al operation , th e patien t dislo-
cated h is THA an d w as treated w ith closed redu ction
( Fig 19 .3 -2 ). A secon d dislocation occu rred 1 m on th later.
Th e treatin g su rgeon decided to im plan t a dou ble m obility
w ou n d an d prolon ged oozin g w as n oted in th e postoperative
period. Du rin g th is tim e, a cu ltu re sw ab w as taken rom th e
w ou n d drain age, w h ich dem on strated m u ltisen sitive Staph-
ylococcus aureus. Th e su rgeon ch ose n on operative treatm en t
u sin g an tibiotics w ith an oral ceph alosporin . Th e clin ical
cou rse revealed th at th e w ou n d did n ot h eal, an d th e su rgeon
decided to per orm a tw o-stage exch an ge w ith pre abricated
spacer ( Fig 19.3 -3 ).

Fig 19.3 -1 The patie nt unde rwe nt total hip
arthroplasty for sym ptom atic arthritis of the right hip
2 ye ars prior to pre se ntation at the author's hospital.
Fig 19 .3-2 Two we e ks afte r the
original ope ration the patie nt
dislocate d his total hip arthroplasty.
Fig 19 .3 -3 The clinical course
re ve ale d that the wound did not
he al, so a two-stage e xchange
with pre fabricate d space r was
pe rform e d.

379
 Se ct io n 3Case s
19.3Im plant
re movalchronically
infe cte d
total
hip
arthroplasty
A ter a 3-m on th in terval an d with n orm alized in f am m atory
param eters (C-reactive protein [CRP], leu kocyte cou n t, an d
eryth rocyte sedim en tation rate) a revision stem w ith dou ble
m obility cu p w as im plan ted. Th e patien t w as treated or
an oth er 6 w eeks w ith an tibiotics w ith u n even t u l in itial
ollow -u p over 6 m on th s. At th at poin t, in creasin g pain w as
n oted w h ile w alkin g an d w as n ot atten u ated by an tiin f am -
m atory m edication . Th e x-rays dem on strated loosen in g
arou n d th e stem ( Fig 19.3-4 ). Th ree m on th s later (12 m on th s
a ter th e last revision ), th e CRP level w as 18 m g/ L an d
eryth rocyte sedim en tation rate w as elevated at 30 m m / h .
Th e patien t w as sen t or specialist care, u rth er in vestigation ,
an d treatm en t.
2 In d ica t io n s
Upon arrival at th e au th ors ou tpatien t clin ic th e patien t
w alked bearin g u ll w eigh t w ith a righ t-sided lim p du e to
pain rom th e righ t leg. Th e scar appeared calm , w ith ou t
redn ess or w arm th . No pain w as n oted on palpation or w h en
m ovin g th e h ip join t.
Fig 19.3 -4 Loose ning around the
ste m in Grue n zone s 1 and 7.
c proxim al fe m ur.
380
3 Pre o p e ra t ive p la n n in g
Th e x-rays sh ow ed sign s o loosen in g in Gru en zon es 1 an d
7 ( Fig 19 .3-4 ). Th e CRP level w as 34 m g/ L.
With th ese n din gs, it appeared likely th at th e patien t h ad
a persisten t or recu rren t in ection o h is THA. Th e au th or
ch ose to proceed directly w ith a tw o-step exch an ge w ith a
sh ort in terval in stead o a on e-step exch an ge du e to m u ltiple
previou s ailed su rgeries. As th e prior an tibiotic treatm en t
w as n ot w ell adapted an d m ay h ave in du ced resistan ce, it
was n ot clear wh eth er an an tibio lm treatm en t was possible
i a on e-step exch an ge w as u sed.
4 Su rgica l a p p ro a ch
A tw o-step exch an ge w as per orm ed w ith osteotom y o th e
proxim al em u r (Wagn er osteotom y) an d th ree cerclage
w ires w ere u sed or xation o th e proxim al em u r
( Fig 19.3-5 ) a ter im plan tation o a h an dm ade cem en t spacer
( Vid e o 19 .3 -1 , Vid e o 10 -1 , Vid e o 10 -2 ). System ic an tibiotics
(am oxicillin -clavu lan ic acid 3 x 2.2 g/ day) w ere given u n til
th e de n itive m icrobiological resu lts.
b
Fig 19.3 -5 a c A two -ste p
e xchange was pe rform e d with
oste otom y of the proximal
fe m ur ( Wagner oste otom y)
and thre e ce rclage wire s
we re use d for xation of the
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Olivie r Bore ns

5 Po s t o p e ra t ive m a n a ge m e n t 6 Re im p la n t a t io n

Th e m icrobiological exam in ation by son ication an d stan dard
m icrobiology dem on strated m eth icillin -resistan t Staphylococcus
epidermidis sen sitive to van com ycin an d ri am pin . Th e day
a ter su rgery th e patien t w as allow ed to get u p to partially
bear w eigh t.
Du e to th e avorable an tibiogram , an an tibio lm treatm en t
w ith ri am pin w as possible, an d th e au th or per orm ed a
sh ort-in terval exch an ge an d reim plan t a n on cem en ted,
dou ble m obility revision stem ( Fig 19.3-5 ).
Th e secon d-stage exch an ge took place 17 days a ter rem oval
o th e revision THA an d w ith ou t stoppin g in traven ou s van -
com ycin preoperatively ( Fig 19 .3 -6 ). Th e cerclage w ires w ere
n ot exch an ged. Postoperatively th e patien t con tin u ed van -
com ycin th erapy in traven ou sly 2 g/ day be ore th e addition
o 2 x 450 m g/ day o ri am pin as soon as th e w ou n d w as
dry. Th e patien t w as disch arged rom th e h ospital 6 days
postoperatively, partially bearin g w eigh t or 6 w eeks an d
adm in istered oral an tibiotic treatm en t (doxycyclin e an d
ri am pin ) or a total o 3 m on th s ( Fig 19.3-7 ).

Vid e o 19 .3-1 Re m oving of an infe cte d total

joint arthroplasty.

Fig 19.3 -6 Postope rative x-ray shows the
se cond-stage e xchange which took place
17 days afte r re m oval of the re vision.
A nonce m e nte d, double m obility re vision
ste m was im plante d.
Fig 19 .3 -7 The patie nt was
discharge d from hospital 6 days
postope rative ly, partially be aring
we ight for 6 we e ks.

381
 Se ct io n 3Case s
19.3Im plant
re movalchronically
infe cte d
total
hip
arthroplasty

7 Ou t co m e 9 Pe a rls

At th e last ollow -u p, 1 year a ter th e last operation an d
9 m on th s a ter stoppin g th e an tibiotic treatm en t, th e CRP
level w as < 1 m g/ L an d th e patien t w as experien cin g n o
pain in th e THA. He w as able to retu rn to w ork u ll-tim e
ven dor ( Fig 19 .3 -8 ).
A rou tin e ollow -u p visit w as recom m en ded 2 years a ter
th e exch an ge procedu re w as per orm ed.
8 Pit fa lls
At th e begin n in g o an tim icrobial treatm en t, alw ays
u se th e best possible in traven ou s an tibiotics. It is n ot
recom m en ded to take oral secon d-gen eration ceph alo-
sporin s or pen icillin s in th e acu te, in itial ph ase.
I th e path ogen respon sible or th e in ection o th e
THA is u n kn ow n , a tw o-stage exch an ge (i possible
sh ort-in terval) is th e best an d sa est treatm en t option .
In th e in terval betw een rem oval o th e in ected THA
an d reim plan tation , ri am pin th erapy m u st n ot be u sed
becau se o in creased risk o occu rren ce o resistan ce.

I a su rgical w ou n d a ter plan n ed su rgery is n ot h ealin g

an d prolon ged oozin g is n oted (< 1 w eek), su rgical
m an agem en t is advised.
Never give em piric an tibiotics w ith ou t or be ore
adequ ate diagn ostic stu dies, su ch as deep cu ltu re.

Fig 19.3 -8 At 1-ye ar follow-up

the patie nt e xpe rie nce d no pain.
The forme r oste otomy was he ale d.

382 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Craig J Della Valle
19.4 Im p la n t re m o va lch ro n ic in fe ctio n a fte r to t a l
kn e e a rth ro p la s t y
Craig J De lla Valle
1 Ca s e d e s crip t io n
A 54-year-old m an presen ted w ith pain ollow in g a prim ary
total kn ee arth roplasty (TKA). Th e in dex procedu re w as
don e at an ou tside h ospital or osteoarth ritis 2 years earlier.
Th e patien ts postoperative cou rse w as com plicated by w ou n d
drain age, w h ich w as in itially treated w ith local w ou n d care
an d even tu ally placem en t o a m edial gastrocn em iu s m u scle
f ap by a plastic su rgeon . Th e kn ee join t w as n ot debrided
at th e tim e o th e secon d su rgical procedu re. Seven m on th s
later, h e com plain ed o sti n ess an d th e origin al su rgeon
per orm ed a m an ipu lation u n der an esth esia w ith little
im provem en t in h is ran ge o m otion or pain . Th e patien t
h ad n o m edical com orbidities an d on ly u sed n arcotic pain
m edication as n eeded.
Ph ysical exam in ation revealed a t m an w ith a w ell-h ealed
scar over th e an terior aspect o th e kn ee an d prior in cision s
con sisten t w ith h is h istory o a gastrocn em iu s m u scle f ap.
Neu rovascu lar statu s w as in tact. Kn ee ran ge o m otion
dem on strated a 10 f exion con tractu re to 85 o f exion an d
a large join t e u sion w as presen t. Plain x-rays sh ow ed a
cem en ted, m obile-bearin g TKA w ith a radiolu cen t lin e
u n dern eath th e tibial im plan t ( Fig 19.4-1 ). Eryth rocyte sedi-
m en tation rate (ESR) w as elevated at 33 m m / h (n orm al
ran ge: 023 m m / h ) an d th e C-reactive protein (CRP) level
w as 20.1 m g/ L (n orm al ran ge: less th an 5 m g/ L). Th e kn ee
w as aspirated an d th e syn ovial f u id sh ow ed 42,000/ L w h ite
blood cell (WBC) cou n t w ith a di eren tial o 97% polym or-
ph on u clear cells; cu ltu res grew Peptostreptococcus.
a b
Fig 19.4-1a b Plain x-rays obtaine d at the tim e of
the initial e valuation showing a ce m e nte d, m obile -
be aring total kne e arthroplasty with som e luce ncy
visible around the tibial im plant.
383
 Se ct io n 3Case s
19.4Implant
removalchronic
infe ction
afte r
total
kne e
arthroplasty

2 In d ica t io n s 4 Su rgica l a p p ro a ch , d e b rid e m e n t , a n d im p la n t

Th e patien t h as a ch ron ic, deep periprosth etic join t in ection .
Option s or m an agem en t in clu de lon g-term su ppressive
an tibiotic th erapy, a on e-stage or a tw o-stage exch an ge
arth roplasty. Lon g-term su ppressive th erapy is gen erally
in dicated or patien ts w h o are u n it or elective su rgery
secon dary to severe m edical com orbidities or in cases w h ere
th e kn ee m ay be n on recon stru ctable a ter rem oval o th e
im plan ts th at are in place. Th is patien t is h ealth y w ith
prim ary im plan ts in place an d h en ce operative in terven tion
is in dicated.
A tw o-stage exch an ge procedu re w as selected or treatm en t.
Th e rst stage in clu des rem oval o th e in ected im plan ts, all
associated cem en t an d in ected-appearin g so t tissu e an d
bon e w ith th e in sertion o an an tibiotic-loaded cem en t
spacer. Follow in g a 6-w eek cou rse o an tibiotics, th e patien t
is observed or 2 w eeks w ith discon tin u ation o an tibiotics
ollow ed by a secon d-stage reim plan tation procedu re at ap-
proxim ately 9 w eeks a ter th e im plan t rem oval an d spacer
placem en t. Expected cu re is 8090% in m ost con tem porary
series.
3 Pre o p e ra t ive p la n n in g
Preoperative plan n in g is critical to th e su ccess o an y revision
arth roplasty. In gen eral, a review o operative n otes is criti-
cal to u n derstan d n ot on ly th e prior su rgical approach bu t
also th e m ake, m odel, an d sizes o th e previou sly im plan ted
com pon en ts. Certain design s m ay requ ire speci c extraction
devices an d kn ow ledge o th is preoperatively m ay be critical.
In gen eral, a review o prior laboratory testin g an d cu ltu re
resu lts can h elp to iden ti y or con rm th e in ectin g organ ism
an d th e associated an tibiotic sen sitivities.
re m o va l
Th e su rgical approach u sed m ost com m on ly or revision
TKA is a m edial parapatellar approach . Th is su rgical approach
provides adequ ate exposu re or m ost revision procedu res
an d can be easily con verted to a m ore exten sile approach ,
su ch as a qu adriceps sn ip or tibial tu bercle osteotom y i
n eeded.
Su rgical exposu re begin s with th e skin in cision , an d i m u ltiple
in cision s are presen t, th e m ost lateral on e th at can be u sed
is selected as th e blood su pply to th e skin is derived pre-
dom in an tly rom th e m edial side. Fu ll-th ickn ess skin f aps
are critical as th e blood su pply ru n s deep, n ear th e deep
ascial plan e, an d su per cial f aps risk skin n ecrosis. Th e
arth rotom y is m ade rom th e apex o th e qu adriceps ten don ,
alon g its ju n ction w ith th e vastu s m edialis an d cu rvin g
arou n d th e patella to th e m edial side o th e tibial tu bercle
( Fig 19.4 -2 ). A com plete an terior syn ovectom y is th en per-
orm ed to both debride in ected syn oviu m an d en h an ce
exposu re; in gen eral it is easy to di eren tiate th e syn oviu m
rom th e exten sor m ech an ism an d capsu le to allow or th e
syn ovectom y to be sa ely per orm ed ( Fig 19 .4 -3 ). Next, th e
in terval betw een th e patellar ten don an d th e proxim al tibia
is care u lly developed to ree th e exten sor m ech an ism rom
th e scar th at is u su ally presen t in th is in terval.
Quadriceps tendon

It is im portan t to preoperatively u se a h olistic approach to

th e patien t in clu din g optim ization o an y associated m edical Patella
com orbidities (su ch as diabetes) w ith th e assistan ce o a
specialist in in tern al m edicin e. Preoperative con su ltation
w ith an in ectiou s diseases specialist is also u se u l to con rm
th e plan or postoperative an tibiotic m an agem en t an d in Tibial tubercle
som e in stan ces to assist w ith th e selection o an tibiotics to
be placed in th e in terim spacer. Man y patien ts w ith ch ron i-
cally in ected total join t arth roplasties are m aln ou rish ed,
an d optim ization o n u trition both be ore th e rst-stage Fig 19.4-2 Me dial parapate llar arthrotom y from the ape x of
an d certain ly be ore th e secon d-stage reim plan tation is the quadrice ps te ndon along the borde r of the vastus m e dialis,
around the pate lla and to the m e dial side of the tibial tube rcle . If
recom m en ded.
e xposure is inade quate afte r a thorough ante rior synove ctomy and
re le ase , a quadrice ps snip can be pe rform e d (dotte d line) across
the quadrice ps te ndon (not in the quadrice ps m uscle).

384 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Craig J Della Valle

Next th e m odu lar polyeth ylen e lin er is rem oved an d an
attem pt is m ade to su blu x th e patella laterally: th is au th or
pre ers su blu xation to eversion ; h ow ever, eversion can also
be attem pted at th is tim e. I n eith er m an eu ver is su ccess u l,
th e n ext step is to peel o so t tissu e rom th e lateral aspect
o th e patella; i th is does n ot provide adequ ate exposu re a
orm al lateral retin acu lar release can be per orm ed. I ex-
posu re is still n ot adequ ate at th is tim e, a qu adriceps sn ip
can be per orm ed ( Fig 19.4-2 ). Th e qu adriceps sn ip is an apical
exten sion o th e arth rotom y across th e qu adriceps ten don
(n ot in th e qu adriceps m u scle) in to th e bers o th e vastu s
lateralis. A qu adriceps sn ip is easy to per orm an d repair,
h eals reliably, an d does n ot requ ire a m odi cation o th e
postoperative regim en . Tibial tu bercle osteotom ies ( Fig 19.4-4 )
are u sed rarely in th is au th ors practice, typically reserved
or cases w h ere th ere is a w ell- xed, u lly cem en ted tibial
stem th at requ ires rem oval ( Fig 19.4-5 ).
Th e im plan ts are rem oved w ith n arrow osteotom es or a th in
saw blade disru ptin g th e cem en t m an tle circu m eren tially.
Th e em oral com pon en t is typically rem oved rst, ollow ed
by th e tibia an d th e patella last w h ich is gen erally easily
rem oved w ith an oscillatin g saw to cu t o th e body o th e
patella rom th e pegs w h ich are rem oved w ith a h igh -speed
bu rr.
Next, th e proxim al tibia is cu t again to debride th e su r ace
u sin g eith er an in tram edu llary or extram edu llary cu ttin g
gu ide ollow ed by a com plete posterior syn ovectom y. In
gen eral th ere are large am ou n ts o scar posteriorly an d th is
tissu e is rem oved u n til at or m u scle is seen in th e posterior
aspect o th e kn ee. Th is n ot on ly u rth er debrides in ected
syn oviu m bu t also en h an ces exposu re by releasin g th e tibia
rom th e em u r. Th e bon y su r aces are all n ow care u lly
exam in ed an d all rem ain in g cem en t or an y residu al bon e
th at appears in ected is rem oved ollow ed by open in g u p
th e em oral an d tibial can als w ith a drill or lon g cem en t
rem oval tool so th at th ey can be debrided as w ell an d to
allow or placem en t o th e spacer. Th e en tire w ou n d is ir-
rigated w ith sterile salin e u sin g pu lsatile lavage. Th e kn ee
is exam in ed again to en su re all retain ed cem en t is rem oved
alon g w ith an y so t tissu e or bon e th at appears in ected,
ollow ed by spacer placem en t.

b
Fig 19.4-3a b The borde r be twe e n the
m e dial capsule and synovium has be e n
m arke d out (a ) to allow for sharp e xcision of
the synovium ( b ).
Fig 19 .4 -4 Tibial tube rcle oste otom y as
se e n from the late ral vie w is made 5 8 cm
in le ngth tape ring from proxim ally to distally
and hinge d ope n from m e dial to late ral
le aving the late ral soft-tissue sle e ve intact.
Fig 19.4-5 AP x-ray showing a fully
ce m e nte d tibial ste m that m ay re quire a
tibial tube rcle oste otomy to re m ove .

385
 Se ct io n 3Case s
19.4Implant
removalchronic
infe ction
afte r
total
kne e
arthroplasty

5 Te m p o ra r y fixa t io n w it h a n a n t ib io t ic-lo a d e d
ce m e n t s p a ce r
An tibiotic-loaded cem en t spacers are u sed rou tin ely in
con tem porary practice to provide local an tibiotic delivery
an d m ain tain so t-tissu e ten sion , w h ich acilitates th e secon d-
stage recon stru ction . Wh ile th e precise am ou n t o an tibiotics
to be m ixed in to th e cem en t is con troversial, th e au th ors
pre eren ce is to u se a h igh -viscosity cem en t m ixed w ith
approxim ately 46 g o an tibiotics per 40 g package o ce-
m en t. In gen eral, h igh -viscosity cem en ts elu te th e an tibiotics
better an d a com bin ation o an tibiotics u rth er prom otes
elu tion . Th e au th ors pre eren ce is typically a com bin ation
o van com ycin an d tobram ycin .
Th e ch oice betw een a static ( Fig 19.4-6 ) an d articu latin g spacer
is again con troversial; h ow ever, th e au th ors pre eren ce
u su ally is an articu latin g spacer ( Fig 19 .4 -7 ). Articu latin g
spacers m ay allow or greater postoperative ran ge o m otion
(as w as a con cern in th is case) an d m ay acilitate th e secon d-
stage recon stru ction as exposu re is easier i th e kn ee can be
f exed an d th e so t tissu es are gen erally m ore pliable. Al-
th ou gh th ey can be m ade by h an d ( Vid e o 10-3 ), th e au th or
pre ers com m ercially available m olds ( Fig 19.4 -8 ) th at allow
or m ore precise sizin g alon g w ith th e ability to adju st th e
th ickn ess o th e tibial spacer to optim ize ran ge o m otion
an d stability. Static spacers are u tilized i th e so t-tissu e
en velope is com prom ised, i th e rem ain in g bon e stock w ill
n ot su pport an articu latin g spacer, or i th e exten sor m ech a-
n ism is disru pted given th e h igh risk o dislocation o an
articu latin g spacer in th is scen ario.

Fig 19.4-6 Static antibiotic space r

cre ate d with two thre ade d Ste inm ann
pins that are coate d with ce m e nt. One
is place d up the fe m oral canal and one
down the tibial canal and the n the y are
allowe d to ove rlap with additional ce m e nt
place d into the kne e joint to cre ate a
te m porary kne e fusion. A thin laye r of
ce m e nt is also place d be twe e n the
e xte nsor me chanism and the distal fe m ur
to facilitate e xposure at the se cond stage . a b

Fig 19.4-7 a b Vie ws of the articulating space r use d for this case .
Note the dowe ls of ce m e nt that have be e n place d into the canals.
The tibial dowel of ce m e nt also stabilize s the tibial space r, acting like
a ste m e xte nsion.
a AP vie w.
b Late ral vie w.

Fig 19 .4 -8 The articulating space r has be e n m ade with com m e rcially available m olds. Ste m
e xte nsions are adde d on to allow for local antibiotic de live ry to the canals and to stabilize the tibial
space r. The tibial space r m old allows the surge on to adjust the thickne ss of the space r to balance
the e xion and e xte nsion gaps m axim izing stability and range of m otion. The intram e dullary
dowe ls are made rst (approxim ate ly 10 m m in diam e te r and 10 cm in le ngth) and allowe d to fully
dry and the n inse rte d into the ce m e nt for the tibial space r while it is harde ning.

386 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Craig J Della Valle
To m ake th e spacer, th e rst step is to m ix on e 40 g batch
o cem en t w ith th e pow dered an tibiotics. Th e au th or h as
ou n d th at a stain less-steel bakin g si ter h elps to m ix th e
an tibiotics an d th e powder portion o th e cem en t ( Fig 19.4-9 ).
Th e rst batch o cem en t is m ixed early in th e case, an d
dow els or th e in tram edu llary can als are con stru cted by
rollin g th e cem en t by h an d in to dow els th at are approxi-
m ately 10 m m in diam eter by 10 cm in len gth w h ich are
allow ed to com pletely h arden . On ce th e em oral com pon en t
h as been rem oved, th e em oral size is selected an d on e to
tw o m ore batch es o cem en t are m ixed w ith an tibiotics an d
placed in to th e m old, w h ich is sim ilarly allow ed to h arden
com pletely. Fin ally, a ter th e tibial com pon en t is rem oved,
th e f exion an d exten sion spacers are ch ecked w ith a spacer
block to determ in e th e optim al th ickn ess o th e tibial spacer
( Fig 19.4-10 ); th e au th or u su ally aim s or a tibial spacer th at
is 2 m m th in n er th an th e optim al tibial spacer block to en su re
th at th e kn ee w ill n ot be too tigh t on ce th e spacer is in serted.
On ce th e tibial spacer size an d th ickn ess h ave been selected,
an oth er batch o cem en t is u tilized to con stru ct th e tibial
spacer an d on e o th e previou sly m ade dow els is in serted
in to it to act like a stem exten sion ; th is w ill both deliver
an tibiotics in to th e tibial can al an d stabilize th e tibial spacer
( Fig 19 .4-8 ).
On ce th e tibial spacer h as h arden ed, th e tou rn iqu et is
released an d h em ostasis obtain ed; a bloody eld at th e tim e
o n al spacer in sertion is desired to en cou rage a su boptim al
cem en t m an tle to acilitate spacer rem oval at th e reim plan -
tation . A n al batch o cem en t is m ixed w ith an tibiotics an d
th e tibial an d em oral spacers are loosely cem en ted in to
place w h en th e cem en t is in th e later stages o h arden in g
to in ten tion ally obtain a poor cem en t m an tle w ith ou t in -
Fig 19.4-9 A stainle ss ste e l sifte r assists Fig 19 .4 -10 A space r block is use d to
with m ixing the antibiotic and ce m e nt de te rm ine the thickne ss of the tibial space r
powde r. to be constructe d.
terdigitation o cem en t in to th e rem ain in g bon e to acilitate
rem oval at th e secon d stage ( Fig 19.4-11 ). On ce th e n al batch
o cem en t h as h arden ed, th e su rgeon sh ou ld assess overall
stability o th e con stru ct an d w h at ran ge o m otion is sa e
an d w ill be allow ed postoperatively. Th e arth rotom y is closed
over a drain an d th e su bcu tan eou s tissu es an d skin are closed
w ith absorbable, n on braided su tu re.
6 Po s t o p e ra t ive m a n a ge m e n t
A m u ltidisciplin ary approach to postoperative m an agem en t
is im portan t to optim ize ou tcom es. As previou sly ou tlin ed,
collaboration w ith in tern al m edicin e an d an in ectiou s
diseases specialist is critical to optim ize an y com orbidities
th at m ay be presen t an d to m on itor th e respon se to an ti-
biotic treatm en t. Patien ts m ay also requ ire n u trition al
optim ization .
An tibiotics are adm in istered based on th e sen sitivities ob-
tain ed rom th e in traoperative or preoperative cu ltu res or
6 w eeks w ith w eekly m easu rem en ts o th e ESR an d CRP
levels. Th e an tibiotics are th en discon tin u ed an d 2 w eeks
later, th e ESR an d CRP levels are ch ecked again , th e kn ee
is aspirated an d th e f u id sen t or a syn ovial f u id WBC cou n t,
di eren tial, an d cu ltu re. In gen eral, th e au th or h as ou n d
th at w h ile th e ESR an d CRP levels sh ou ld decrease, th ey
w ill n ot alw ays retu rn to n orm al prior to th e proposed
reim plan tation at approxim ately 9 w eeks a ter th e rst-stage
procedu re. Hen ce, th ere is n o speci c cu t-o or determ in -
in g in ection resolu tion bu t th e tren d o th ese laboratory
resu lts sh ou ld be dow n w ard an d th is tren d sh ou ld con tin u e
a ter an tibiotic cessation . I th e ESR an d CRP levels in crease
Fig 19.4-11 The nal space r is in place and
stability and range of m otion are asse sse d.
387
 Se ct io n 3Case s
19.4Implant
removalchronic
infe ction
afte r
total
kne e
arthroplasty
ollow in g discon tin u ation o an tibiotic th erapy, th is is
particu larly con cern in g or persisten ce o in ection . A sy-
n ovial f u id WBC cou n t over 3,000 cells/ L an d a di eren tial
o > 80% are likew ise con cern in g or persisten t in ection ,
as is a positive syn ovial f u id cu ltu re.
Follow in g an tibiotic spacer placem en t, patien ts are in itially
placed in a kn ee im m obilizer, w h ich is con verted to a h in ged
kn ee brace on th e rst or secon d postoperative day. I th ere
is an y con cern regardin g th e so t-tissu e en velope, th e kn ee
sh ou ld be im m obilized or lon ger. Th e h in ged kn ee brace is
set to allow ran ge o m otion as w as determ in ed to be sa e
in traoperatively; in gen eral th e au th ors allow patien ts 090
ran ge o m otion an d i th e kn ee w as stable in traoperatively,
th ey are allow ed to bear w eigh t as tolerated w h ile w earin g
th e h in ged kn ee brace. I th ere is an y con cern regardin g
kn ee stability or xation o th e spacer, m ore lim ited w eigh t
bearin g is recom m en ded.
7 Re im p la n t a t io n
At 9 w eeks postoperatively th e patien t is retu rn ed to th e
operatin g room w h ere eith er a reim plan tation procedu re is
per orm ed or th e spacer is exch an ged; th e secon d-stage
procedu re is on ly delayed i m edical com orbidities or n u -
trition al statu s requ ires optim ization . Th is is a secon d ch an ce
to debride th e kn ee join t an d rem ove an y devitalized or
in ected-appearin g bon e or so t-tissu e. Mu ltiple tissu e an d
bon e cu ltu res (typically ve or m ore) are obtain ed an d an
in traoperative rozen section can be u sed as a n al ch eck to
con rm or den y persisten t in ection . Th e su rgeon sh ou ld
be aw are, h ow ever, th at in traoperative rozen section in -
terpretation can be ch allen gin g even or an experien ced
path ologist. Fu rth er, rozen section s are su bject to sam plin g
error (eg, i th e w ron g tissu e sam ples are sen t to th e path olo-
gist, th ey can be alsely n egative). Gram stain s h ave little
valu e in th e diagn osis o periprosth etic join t in ection an d
th eir u se is discou raged, as th ey are n ot sen sitive en ou gh
an d can also be alsely positive w h ich on ly con u ses
m an agem en t.
388
Th e spacer sh ou ld be easily rem oved an d th e bon y su r aces
are cu t again w ith a saw to both debride th em on ce again
an d to prepare th em or cem en tation o th e revision com -
pon en ts. A ter th e bon e su r aces are debrided th e w ou n d is
again copiou sly irrigated w ith sterile salin e u sin g pu lsatile
lavage. Th e kn ee is prepared to accept th e revision com -
pon en ts w h ich are in serted u sin g a h ybrid cem en tin g
tech n iqu e w h ere com m ercially available an tibiotic-loaded
cem en t (typically 0.5 g o gen tam icin per 40 g package o
cem en t) is placed n ear th e articu lar portion s o th e im plan t;
h ow ever, th e stem exten sion s are n ot cem en ted bu t tigh tly
press t in to th e respective diaph ysis o th e tibia an d em u r
( Fig 19 .4 -12 ). Addition al or altern ative an tibiotics can be added
to th e cem en t, particu larly i th e in ectin g organ ism is n ot
sen sitive to gen tam icin ; h ow ever, u su ally, m ost su rgeon s
pre er to n ot exceed 1 g o an tibiotics per 40 g o cem en t
w h en u sed or xation o th e revision im plan ts as m ore th an
th is m ay com prom ise th e stren gth o th e cem en t.
Proph ylactic an tibiotics are adm in istered prior to th e skin
in cision , an d u su ally in clu de a rst-gen eration ceph alosporin
(su ch as ce azolin ) an d van com ycin ; th is m ay be altered,
h ow ever, i th e origin al in ectin g organ ism is n ot adequ ately
covered by th e above com bin ation . An tibiotics are con tin u ed
u n til n al operative cu ltu res are n egative or con tin u ed i
th ere is an y con cern regardin g in ection persisten ce. Th e
decision to con tin u e or discon tin u e an tibiotics is u su ally
m ade in con ju n ction w ith th e in ectiou s disease specialist.
Fig 19.4-12 The re vision com pone nts are inse rte d using a hybrid
ce m e nting te chnique whe re antibiotic-loade d bone ce m e nt is place d
ne ar the articular surface s, and a ce m e ntle ss ste m is tightly pre ss t
into the diaphysis.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Craig J Della Valle
8 Ou t co m e
Th e patien t u n derw en t rem oval o th e in ected TKA an d
placem en t o an articu latin g spacer ( Fig 19.4 -7 ); a plastic su r-
geon assisted w ith th e exposu re given th e prior f ap proce-
du re. Th e patien t received 6 w eeks o in traven ou s an tibiotics
an d h is ESR an d CRP levels sh ow ed progressive decreases;
h is w ou n d h ealed u n even t u lly. His an tibiotics w ere stopped
an d 2 w eeks later, at 8 w eeks postoperatively, th e ESR level
h ad decreased to 5 m m / h (n orm al ran ge: 023 m m / h ) an d
th e CRP level w as < 5 m g/ L (n orm al ran ge: less th an 5 m g/ L).
Th e kn ee w as aspirated an d it sh ow ed 1,057 WBC/ L w ith
a di eren tial o 61% polym orph on u clear cells; cu ltu res
sh ow ed n o grow th .
At th e tim e o reim plan tation (9 w eeks ollow in g rem oval
o th e in ected arth roplasty) a plastic su rgeon assisted w ith
elevation o th e prior f ap an d w ou n d closu re. Th e in traop-
erative rozen section w as n egative as w as th e n al h isto-
path ology an d all ve tissu e cu ltu res. Th e revision im plan ts
w ere in serted w ith a h ybrid cem en tin g tech n iqu e w h ere
th e epiph yseal portion is cem en ted an d th e stem exten sion s
are tigh tly press t in to th e diaph ysis ( Fig 19 .4 -12 , Fig 19 .4-13 ).
An tibiotics w ere discon tin u ed 72 h ou rs postoperatively. Th e
patien t, h ow ever, stru ggled to regain h is ran ge o m otion ,
an d 6 weeks a ter th e reim plan tation h e h ad ran ge o m otion
rom a 5 f exion con tractu re to 75 o u rth er f exion . He
u n derw en t a m an ipu lation u n der an esth esia an d 2 years
postoperatively h as ran ge o m otion rom u ll exten sion to
100 o f exion .
a b
Fig 19.4-13a b Vie ws of the re vision construct inse rte d with a
hybrid ce m e nting te chnique with ce m e nt in the e piphysis and ste m
e xte nsions that are tightly pre ss t into the diaphysis.
a AP vie w.
b Late ral vie w.
9 Pit fa lls
Decision m akin g: debridem en t alon e is associated w ith
a h igh rate o ailu re w h en treatin g a patien t w ith
ch ron ically in ected TKA.
Th e su rgical approach sh ou ld be gen erou s to allow or
a com plete syn ovectom y an d th e sa e rem oval o
im plan ts an d associated cem en t.
Im plan t rem oval sh ou ld com m en ce at th e in ter aces
betw een th e im plan t an d th e cem en t m an tle, an d n ot
betw een th e cem en t m an tle an d th e h ost bon e as th is
can lead to excessive bon e rem oval.
Great care sh ou ld be taken to rem ove an y associated
cem en t an d in ected-appearin g bon e an d so t tissu e;
retain ed cem en t is probably th e m ost com m on reason
or recu rren ce o in ection a ter spacer placem en t.
Th e su rgeon sh ou ld strive or a poor cem en t m an tle
w h en in sertin g th e tem porary spacer by h avin g a
bloody eld at th e tim e o cem en tation .
Medical an d n u trition al optim ization betw een stages is
im portan t to optim ize ou tcom es.
It can be di cu lt to determ in e w h en th e in ection h as
been eradicated; th e au th or typically relies on observa-
tion o th e tren d o th e ESR an d CRP; th ey sh ou ld
sh ow steady decreases ollow in g rem oval o th e
im plan t bu t in m an y cases do n ot com pletely n orm alize
prior to reim plan tation at 9 w eeks; i th e ESR an d CRP
levels in crease a ter cessation o an tibiotic th erapy,
du rin g th e an tibiotic h oliday, th is is con cern in g or
persisten t in ection .
Th e su rgeon sh ou ld view th e reim plan tation procedu re
as a secon d ch an ce to debride th e w ou n d, w h ich
sh ou ld be don e th orou gh ly to avoid th e reten tion o
an y associated cem en t or n on viable in ected-appearin g
bon e or so t tissu e.
389
 Se ct io n 3Case s
19.4Implant
removalchronic
infe ction
afte r
total
kne e
arthroplasty
10 Pe a rls
Diagn osis: a patien t w ith a pain u l, sti , or oth erw ise
sym ptom atic TKA sh ou ld be evalu ated or in ection
w ith a seru m ESR an d CRP ollow ed by an aspiration
o th e join t i th e seru m tests are elevated or i th e
clin ical su spicion or in ection is h igh .
Diagn osis: an aspiration o th e kn ee join t is probably
th e m ost valu able sin gle test, yieldin g a syn ovial f u id
WBC cou n t (optim al cu t-o valu e or diagn osin g
in ection approxim ately 3,000 cells/ L), di eren tial
(optim al cu t-o valu e approxim ately 80% ) an d
cu ltu re.
Workin g closely w ith an in ectiou s diseases specialist is
h elp u l or optim izin g an tibiotic m an agem en t.
I su rgical exposu re is in adequ ate despite a th orou gh
syn ovectom y, reestablish m en t o th e space betw een
th e patellar ten don an d tibia an d a lateral retin acu lar
release, th e su rgeon sh ou ld h ave a low th resh old to
per orm a qu adriceps sn ip.
Kn ow ledge o th e im plan ts in place can acilitate th eir
rem oval.
I a static spacer is selected (as opposed to a m obile
spacer), a th in layer o cem en t placed in th e su prapa-
tellar pou ch w ill acilitate exposu re at th e secon d-stage
procedu re.
Th e au th or strives to recon stru ct th e patella at th e tim e
o reim plan tation , as Glyn n et al su ggest th e ou tcom es
are better i th e patella is resu r aced as opposed to le t
u n resu r aced at th e secon d-stage reim plan ation . I le t
u n resu r aced, th e patella ten ds to track laterally
cau sin g pain an d in stability. I bon e loss o th e patella
is severe, im paction bon e gra tin g is an easy an d
reliable solu tion or recon stru ction yieldin g a con vex
stru ctu re th at is easily captu red in th e em oral
troch lea.
Close collaboration with an in ectiou s diseases specialist
h elps in th e selection o an tibiotics or in clu sion in th e
cem en t spacer as w ell as ollow in g th e rst-stage
procedu re.
In terestin gly, ailu res o th erapy seem o ten tim es to be
n ew in ection s, w ith n ew organ ism s iden ti ed at th e
tim e o rein ection in approxim ately tw o o th ree cases.
390
11 Fu r t h e r re a d in g
De lla Va lle C, Pa r vizi J, Ba u e r TW, e t a l. Diagn osis o per iprosth etic
join t in ection s o th e h ip an d k n ee. J Am Acad Orthop Surg. 2010
Dec;18(12):760 770.
De lla Va lle CJ, Be rge r RA, Ro s e n b e rg AG. Su rgical ex posu res in
revision total k n ee arth roplasty. Clin Orthop Relat Res. 2006
May;4 46:59 68.
De lla Va lle CJ, Sp o re r SM, Ja co b s JJ, e t a l. Preoperative testin g or
sepsis be ore revision total k n ee arth roplasty. J Arthroplasty. 2007
Sep;22(6 Su ppl 2):90 93.
Glyn n A, Hu a n g R, Mo r t a za vi J, e t a l. Th e im pact o patellar
resu r acin g in two-stage revision o th e in ected total k n ee
arth roplasty. J Arthroplasty. 2014 Ju l;29(7):1439 42.
Ja co fs k y DJ, De lla Va lle CJ, Me n e gh in i RM, e t a l. Revision total
k n ee arth roplasty: w h at th e practicin g orth opaedic su rgeon n eeds
to kn ow. J Bone Joint Surg Am. 2010 May;92(5):1282 1292.
Ku s u m a SK, Wa rd J, Ja co fs k y M, e t a l. Wh at is th e role o
serological testin g between stages o two-stage recon stru ction o
th e in ected prosth etic k n ee? Clin Orthop Relat Res. 2011
Apr il;4 69(4):1002 1008.
Pa r vizi J, Zm is t o w s ki B, Be rb a ri EF, e t a l. New de n ition or
periprosth etic join t in ection : rom th e Workgrou p o th e
Mu scu loskeletal In ection Society. Clin Orthop Relat Res. 2011
Nov;469(11):29922994.
Sa h AP, Sh u k la S, De lla Va lle CJ, e t a l. Modi ed h ybrid stem
xation in revision TKA is du rable at 2 10 years. Clin Orthop Relat
Res. 2011 Mar;4 69(3):839 8 4 6.
Sh e rre ll JC, Fe h rin g TK, Od u m S, e t a l. Th e Ch itran jan Ran awat
Award: Fate o two-stage reim plan tation a ter ailed irr igation an d
dbridem en t or periprosth etic k n ee in ection . Clin Orthop Relat Res.
2011 Jan ;4 69(1):18 25.
Te t re a u lt MW, We t t e rs NG, Agga r w a l V, e t a l. Th e Ch itran jan
Ran awat Award: Sh ou ld proph ylactic an tibiotics be w ith h eld prior
to revision su rger y to obtain appropriate cu ltu res? Clin Orthop Relat
Res. 2014 Jan ;472(1):52 56.
Va n Th ie l GS, Be re n d KR, Kle in GR, e t a l. In traoperative m olds to
create an articu latin g spacer or th e in ected k n ee arth roplasty.
Clin Orthop Relat Res. 2011 Apr;469(4):994 1001.
Yi PH, Fra n k RM, Va n n E, e t a l. Is poten tial m aln u trition associated
w ith septic ailu re an d acu te in ection a ter revision total join t
arth roplasty? Clin Orthop Relat Res. 2015 Jan ;473(1):175 182.
Zm is t o w s k i B, Te t re a u lt MW, Alija n ip o u r P, e t a l. Recu rren t
periprosth etic join t in ection : persisten t or n ew in ection?
J Arthroplasty. 2013 Oct;28(9):14 86 14 89.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Ste phen L Kate s, Christophe r J Drinkwater
19.5 Im p la n t re m o va lin fe cte d to t a l kn e e
re p la ce m e n t
Ste p he n L Kate s, Christo ph e r J Drinkwate r
1 Ca s e d e s crip t io n
A 43-year-old w om an w ith severe di u se pigm en ted
villon odu lar syn ovitis (PVNS) h ad previou sly u n dergon e
exten sive su btotal syn ovectom y as w ell as direct popliteal
ossa exposu re or open resection o extraarticu lar PVNS,
ollow ed by radiation th erapy. Sh e h ad n ot h ad recu rren ce
o PVNS bu t w en t on to develop progressively w orsen in g
arth ritic ch an ges w ith su bch on dral cysts an d recu rrin g
sw ellin g. Sh e u n derw en t total kn ee replacem en t (TKR).
Six m on th s a ter TKR sh e developed sw ellin g an d kn ee pain .
Th e kn ee w as aspirated an d cu ltu res w ere positive or m eth -
icillin -sen sitive Staphylococcus aureus. Th e C-reactive protein
(CRP) level w as 235 m g/ L. Sh e th en u n derw en t irrigation ,
debridem en t, an d polyeth ylen e exch an ge in th e h ope o
preservin g h er im plan ts. Sh e w as treated w ith in traven ou s
van com ycin . X-rays 2 m on th s later dem on strated radiolu cen t
lin es at th e bon e-cem en t in ter ace su ggestin g th at th e
prosth esis w as bein g u n derm in ed by th e in ectiou s process,
represen tin g in ectiou s loosen in g o th e im plan ts ( Fig 19.5-1 ).
a b c
Fig 19.5-1a c Radioluce nt line s at the bone -ce m e nt inte rface and
im plant m igration sugge st that the prosthe sis is be ing unde rm ine d
by the infe ction. The se x-rays we re m ade 8 m onths afte r the initial
total kne e re place m e nt proce dure . Initial postope rative x-rays did not
de m onstrate any radioluce nt line s or varus alignm e nt.
2 In d ica t io n s
Th e patien t h ad persisten t severe pain in th e in ected total
kn ee join t w h ich is re ractory to irrigation an d debridem en t
an d is also cau sin g debilitatin g loss o u n ction an d disru ption
to a satis actory li estyle. Wh ile sh e is n ot system ically ill,
th e patien t requ ested th e in ected TKR be explan ted in an
attem pt to redu ce pain an d cu re th e in ection as a tw o-stage
su rgery. In th e presen ce o radiograph ic ch an ges, debridem en t,
irrigation , an d polyeth ylen e exch an ge are con train dicated.
3 Pre o p e ra t ive p la n n in g
Wh en preparin g or im plan t rem oval, an en tire set o cem en t
osteotom es an d rem oval tools is pre erred ( Fig 19.5-2 ). In th e
even t th at th ese are u n available, th e stan dard set o osteo-
tom es an d a large bon e tam p are th e m in im u m requ ired
in stru m en ts. A sm all oscillatin g saw , typically pn eu m ati-
cally operated, is extrem ely u se u l to saw th rou gh th e cem en t
o th e em oral an d tibial im plan ts. Th is allow s or a clean er
rem oval o th e im plan ts an d preservation o bon e stock. Th e
au th ors do n ot recom m en d th e u se o th e Gigli saw as it
seem s to sacri ce m ore bon e th an is n ecessary.
Fig 19.5-2 A se t of ce m e nt oste otom e s and prosthe sis-spe ci c
re m oval tools.
391
 Se ct io n 3Case s
19.5
Implant
re movalinfe cte d
total
kne e
re placeme nt

4 Su rgica l a p p ro a ch

A m edial parapatellar arth rotom y (w h ich w as th e prior

su rgical approach ) is u sed or TKR. Typically, th e pn eu -
m atic tou rn iqu et is u sed to redu ce bleedin g an d im prove
visu alization o th e operative ield. Th e th icken ed join t
capsu le an d ten don tissu e are en cou n tered an d m u st be
care u lly dissected an d retracted to provide com plete exposu re
o th e in ected prosth esis ( Fig 19 .5 -3 ). It m ay be n ecessary to
exten d th e origin al exposu re proxim ally an d distally. To
obtain th is exposu re, it is n ecessary to h ave a u ll set o kn ee
join t retractors available. In som e cases, th e patellar clam p
u sed to im plan t th e patellar bu tton m ay be u sed to gen tly
evert th e patella.

b c
Fig 19.5-3 a c Surgical approach.
a Draping the e xtre mity fre e e nable s good e xposure . Ste rile te chnique is use d throughout the proce dure .
b Care ful e xposure of the prosthe sis is achie ve d by ge ntly e xposing the fe m oral and tibial im plants.
c The pate llar im plant is now e xpose d e nabling prope r e xplantation.

392 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Ste phen L Kate s, Christophe r J Drinkwater

5 Su rgica l d e b rid e m e n t

Su rgical debridem en t is con du cted m eth odically an d du rin g

th e cou rse o th e procedu re ( Fig 19.5-4 , Fig 19 .5 -5 , Fig 19.5-6 ).
Th is in volves drain age o an y pu ru len t liqu id, rem oval o
in ected syn ovial tissu e, rem oval o all rem ain in g bon e
cem en t, rem oval o all im plan ts, an d bru sh in g or ream in g
th e in tram edu llary can al o th e em u r an d tibia. Special
atten tion m u st be paid to th e recess beh in d th e em u r to be
certain th at all in ected tissu e, cem en t, an d debris are rem oved.
Irrigation w ith a jet-pu lsed salin e lavage tool is u se u l to
better visu alize th e rem ain in g devitalized tissu e an d cem en t.

Fig 19 .5 -4 Je t lavage use d during de bride me nt.

Fig 19.5-5 Re m oval of ce m e nt from the

tibial canal ofte n re quire s use of a longe r
clam p to e xtract ce m e nt fragm e nts.

Fig 19.5-6 De bride m e nt has be e n

succe ssfully com ple te d and the joint is re ady
for antibiotic space r place m e nt.

393
 Se ct io n 3Case s
19.5
Implant
re movalinfe cte d
total
kne e
re placeme nt

6 Im p la n t re m o va l blade is best) an d cem en t ch isels. A dogleg-sh aped ch isel

It is easier to rem ove th e fem oral im plan t in itially in a
m eth odical m an n er as sh ow n in Fig 19 .5 -7 , Fig 19 .5 -8 ,
Fig 19.5-9 . On ce th e fem oral im plan t h as been loosen ed, it
can be driven off th e distal fem u r an d in a distal direction
w ith a V-sh aped tam p.
Next, th e tibial im plan t is rem oved. Th e cem en t-bon e in -
terface is freed w ith a sm all oscillatin g saw (a 1 cm w ide
w orks w ell in th e posterior aspect of th e tibial im plan t w h ere
a n orm al ch isel can n ot easily reach . Wh en th e im plan t h as
been sligh tly loosen ed, it can be driven u pw ard w ith th e
V-sh aped tam p.
Th e patella im plan t is best rem oved w ith th e sm all oscillat-
in g saw w ith 1 cm blade. If an y cem en t rem ain s in th e lu g
h oles of th e patellar im plan t, a h igh -speed rou n d or football-
sh aped bu rr can be u sed to carefu lly rem ove th e cem en t.

Fig 19.5-8 The fe m oral im plant is re m ove d with a V-shape d tam p.

Fig 19.5-7 A ce m e nt chise l is use d to fre e the bone -

ce m e nt inte rface at the fe m oral im plant.

Fig 19.5-9 The bone -ce m e nt inte rface is fre e d with a sm all
oscillating saw.

394 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Ste phen L Kate s, Christophe r J Drinkwater

7 Te m p o ra r y fixa t io n

A tem porary articu latin g an tibiotic spacer ( Vid e o 10-3 ) is n ow

created u sin g actory m olds ( Fig 19 .5 -10 , Fig 19 .5 -11 ). Th e
cem en t is loaded w ith gen tam icin an d van com ycin , w h ich
w ill elu te over th e f rst w eek a ter im plan tation . Alth ou gh
th ese are an atom ically sh aped im plan ts, th ey do n ot u n ction
as w ell as a TKR. Th ey m ain tain th e space or th e n ext e ort
at replacem en t.

Fig 19.5-10 A m olde d te m porary antibiotic space r. Fig 19.5-11 Molde d antibiotic space r installe d in the joint space .

395
 Se ct io n 3Case s
19.5
Implant
re movalinfe cte d
total
kne e
re placeme nt

8 Po s t o p e ra t ive m a n a ge m e n t 9 Re im p la n t a t io n

Postoperatively, th e patien t is m an aged in a rem ovable
h in ged kn ee brace ( Fig 19 .5 -12 ). Weigh t bearin g as tolerated
is perm itted. Th e in ection itsel is m an aged u sin g a cen tral
ven ou s lin e w ith in traven ou s an tibiotics. Th e an tibiotic
ce azolin w as adm in istered in traven ou sly an d a 6-w eek
period o an tibiotic th erapy w as prescribed w ith th e h elp o
th e in ectiou s diseases ph ysician . Mon th ly CRP levels an d
eryth rocyte sedim en tation rates (ESR) w ere ch ecked. Wh en
th e CRP reach ed a low level (typically 1 m g/ L or less),
reim plan tation w as sch edu led.
At 6 w eeks a ter explan tation o th e in ected TKR, th e patien t
w as ready or reim plan tation . Th e ESR an d CRP levels w ere
redu ced n icely rom preoperative valu es. Th e patien t com -
pleted a 6-w eek cou rse o ce azolin . Th e in cision h ealed w ell
w ith ou t drain age ( Fig 19.5-13 ).
A ter appropriate discu ssion w ith th e patien t, TKR w as
plan n ed. Stan dard su rgical preparation w as per orm ed an d
position in g w as typical or revision TKR ( Fig 19 .5 -14 ).

Fig 19.5-13 The incision he ale d we ll 6 we e ks afte r e xplantation.

a b
Fig 19.5-12a b Postope rative x-rays
following the e xplantation of total kne e
re place m e nt de m onstrate acce ptable
positioning of the ce m e nt space rs. The se
x-rays we re take n with a hinge d kne e
brace in place .

Fig 19.5-14 Standard surgical pre paration and positioning for

re vision total kne e re place m e nt.

396 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Ste phen L Kate s, Christophe r J Drinkwater
Su rgical exposu re in th is situ ation can be tediou s. Care u l
su rgical dissection is essen tial to n d appropriate tissu e
plan es. Th e qu adriceps m ech an ism is exposed an d th e
m edial arth rotom y is per orm ed ( Fig 19.5-15 ).
On ce th e spacer is exposed, it is u su ally n ecessary to rem ove
it in pieces ( Fig 19.5-16 ). Osteotom es an d a m allet are u sed
to rem ove th e spacer.
A ter th e spacer is rem oved, m eth odical debridem en t is
per orm ed an d th e bon es are prepared or rein sertion o
TKR. Th e degree o bon e de cit w ill determ in e th e n eed or
prim ary or revision im plan ts. In th is case, m in im al bon e
Fig 19.5-15 Care ful surgical e xposure and disse ction is e sse ntial to
pe rform m e dial arthrotom y.
Fig 19.5-17 Comple te d e xposure in pre paration
for total kne e re place m e nt.
loss was presen t an d prim ary im plan ts were u sed or revision .
Th e com pleted exposu re is sh ow n in Fig 19.5-17 . In traopera-
tive Gram stain , aerobic an d an aerobic cu ltu res, an d rozen
section w ere sen t or an alysis du rin g su rgery. Th e rozen
section sh ow ed on e n u cleated cell per h igh -pow er eld an d
n o eviden ce o acu te in lam m ation . At th is tim e, 2 g o
in traven ou s ce azolin w ere adm in istered or su rgical pro-
ph ylaxis.
At th is poin t, stan dard TKR tech n iqu e is u sed to n ish th e
procedu re. Ce azolin w as con tin u ed or 24 h ou rs a ter th e
revision su rgery an d th en discon tin u ed. Th e in traoperative
cu ltu res w ere n egative or bacterial grow th .
Fig 19.5-16 Afte r e xposure it is usually ne ce ssary to re m ove the
space r with oste otom e s and a malle t.
397
 Se ct io n 3Case s
19.5
Implant
re movalinfe cte d
total
kne e
re placeme nt

10 Ou t co m e 11 Pit fa lls

Th e x-rays in Fig 19 .5 -18 dem on strate a satis actory TKR.
Prim ary kn ee im plan ts w ere u sed in th is case or revision .
O ten tim es, it w ill be n ecessary to u se con strain ed or h in ged
prosth eses th at sh ou ld be available at th e tim e o th e secon d-
stage su rgery.
In th is case, th e in cision w as properly h ealed at 2 w eeks an d
staples w ere rem oved. Th e patien t started ph ysical th erapy
on postoperative day 1. Sh e regain ed ran ge o m otion o
0105 by 4 m on th s an d w as satis ed w ith th e ou tcom e.
Her CRP an d ESR levels retu rn ed to th e n orm al ran ge. Th ere
w as n o eviden ce o recu rren ce o in ection . Fig 19 .5 -19 sh ow s
x-rays taken at 9 m on th s.
Diagn osis an d decision m akin g: it is essen tial to h ave a
correct m icrobiological diagn osis prior to th e debride-
m en t an d explan tation su rgery. Th is can avoid u se o
an in correct an tibiotic regim en an d in correct an tibiotics
in th e spacer. A com m on error seen in practice is th e
u se o repeated irrigation , debridem en t, an d spacer
exch an ge. Typically, an irrigation an d debridem en t
procedu re sh ou ld be don e n o m ore th an on ce prior to
a de n itive debridem en t an d explan tation . Su rgical
ju dgm en t sh ou ld in clu de a care u l assessm en t o th e
viability o so t tissu es in an d arou n d th e kn ee join t.
Th e presen ce o n ecrotic tissu e sh ou ld bias th e su rgeon
tow ard an early secon d-look debridem en t a ter
explan tation . In som e cases, an early arth rodesis m ay
be requ ired. Th e presen ce o gan gren e or gas- orm in g
organ ism s m ay n ecessitate am pu tation as a de n itive
early procedu re. Alth ou gh u n com m on , th is is som etim es
n ecessary in su ch cases.

a b c d
Fig 19.5-18a d Postope rative x-rays de m onstrate that satisfactory total kne e
re place m e nt has be e n accom plishe d on AP ( a b ), late ral (c ), and pate llar (d ) vie ws.

a b c d
Fig 19.5-19 a d X-rays de m onstrate satisfactory total kne e re place m e nt appe arance at 9 m onths afte r
re vision of total kne e re place m e nt.

398 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Ste phen L Kate s, Christophe r J Drinkwater
Su rgical approach : typically, th e prior su rgical in cision
an d arth rotom y are reu sed. It m ay be n ecessary to
exten d th e in cision s proxim ally an d distally to ach ieve
better exposu re. In som e cases, partial release o th e
patellar ten don attach m en t m ay be requ ired to ach ieve
exposu re. Excellen t exposu re is essen tial to su ccess-
u lly per orm a good debridem en t an d im plan t rem oval.
Th is can be particu larly ch allen gin g w h en patien ts
h ave u n dergon e m u ltiple prior su rgeries w ith scarred
tissu es. Obesity also con siderably com plicates th e
situ ation .
Im plan t rem oval: preparation or im plan t rem oval
dram atically expedites th e process. Th is in clu des
h avin g th e correct cem en t ch isels, a sm all oscillatin g
saw , an tibiotic cem en t, an d m olds, as n eeded. Depen d-
in g on th e particu lar situ ation , it can be ch allen gin g to
rem ove th e im plan ts. Th is is particu larly th e case w ith
lon g-stem revision kn ee replacem en ts th at are solidly
xed bu t actively in ected. In su ch cases, it is essen tial
to h ave a u ll set o cem en t rem oval ch isels, ream ers,
an d a good strategy to su ccess u lly rem ove th e revision
im plan ts.
Tem porary xation : in m ost cases, th e u se o in tern al
polym eth ylm eth acrylate (PMMA) spacers represen ts
th e best strategy. Th ese are typically m ade o an tibiotic-
laden PMMA cem en t. Bracin g th e extrem ity in a
h in ged kn ee brace is u su ally n ecessary to provide
en ou gh stability or th e patien t to be m obilized a ter
su rgery.
Reh abilitation : in m ost cases, th e patien t w ill be able to
bear w eigh t on w ell-m ade PMMA spacers w ith a
h in ged kn ee brace. Th erapy is directed at m obilization
an d am bu lation . Work on ran ge o m otion is u su ally
n ot possible u n til de n itive revision is per orm ed.
Reim plan tation : th e prim ary pit all w ith reim plan ta-
tion is rein ection . Th is is best avoided by care u l
preoperative assessm en t or in ection be ore reim plan -
tation su rgery. Th e preoperative assessm en t con sists o
diagn ostic w orku p, clin ical assessm en t, radiograph ic
assessm en t, an d n eedle aspiration o th e join t space
w ith m icrobiological an alysis. Prior to im plan tin g th e
n ew TKR, a rozen section o th e syn ovial tissu e is
u se u l to ru le ou t acu te in f am m ation . Du rin g reim -
plan tation , alw ays obtain n ew tissu e specim en s or
m icrobiological an alysis. I th e in traoperative cu ltu res
are positive a ter reim plan tation , lon g-term an tibiotic
m an agem en t w ill likely be requ ired.
Failu re o th erapy: in som e cases, th e rst stage o
explan tation w ill ail to clear th e in ection or con trol it.
At th is tim e, it w ill be n ecessary to h ave a team
discu ssion abou t treatm en t goals. Option s or treatm en t
in clu de repeated debridem en t an d an tibiotic spacer
replacem en t, con version to an arth rodesis, or in severe
cases am pu tation m ay be requ ired. Th ere exists a sm all
percen tage o patien ts w h o declin e to h ave an y
addition al treatm en t a ter explan tation is per orm ed.
For th ese patien ts, lon g-term bracin g an d su ppressive
an tibiotic th erapy m ay be n eeded.
12 Pe a rls
Decision m akin g: w h en per orm in g explan tation o a
TKR, th e keys to su ccess are correct diagn osis, m eticu -
lou s preoperative plan n in g, an d w orkin g as a team
w ith an in ectiou s diseases ph ysician . Su rgery sh ou ld
be sch edu led w h en adequ ate h elp is available to sa ely
per orm th e procedu re.
Su rgical approach : m eticu lou s atten tion to detail,
obtain in g w ide exposu re, an d h avin g adequ ate
person n el to h elp are essen tial.
Im plan t rem oval: care u l atten tion to breakin g dow n
th e bon e-cem en t in ter ace w ith th e oscillatin g saw
ollow ed by u se o cem en t-rem oval ch isels greatly
sim pli es th e process o im plan t rem oval.
Tem porary ixation : cem en t-spacer m oldin g an d abri-
cation sh ou ld perm it early m obilization o th e patien t.
Care u lly m akin g th ese w ith actory m olds or h an d
m oldin g are essen tial. Som e lim ited xation w ith
cem en t to h ost bon e is desirable to preven t dislocation .
De n itive revision secon d stage: care u l exposu re
dram atically sim pli es reim plan tation . Havin g prim ary
im plan ts, a con strain ed kn ee system , an d a h in ged
system available o ers m an y option s an d im proves th e
ch an ces or su ccess.
An tibiotic m an agem en t: u se on ly speci c an tibiotics to
wh ich th e organ ism is sen sitive. Ask an in ectiou s
diseases ph ysician or advice on dosage an d du ration o
th erapy.
399
 Se ct io n 3Case s
19.5
Implant
re movalinfe cte d
total
kne e
re placeme nt

400 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Arthur Grze siak, Alain Farron

19.6 Im p la n t re m o va lin fe cte d to t a l s h o u ld e r

a rth ro p la s t y
Arth ur Grze siak, Alain Farro n

1 Ca s e d e s crip t io n Th e recovery process was good an d th e patien t retu rn ed to

A 59-year-old m ale baker w ith type 2 diabetes m ellitu s an d
arterial h yperten sion u n derw en t le t total sh ou lder arth ro-
plasty or sym ptom atic osteoarth ritis treated con servatively
or m an y years ( Fig 19 .6 -1 , Fig 19 .6 -2 ).
part-tim e w ork 3 m on th s a ter su rgery. Five m on th s post-
operatively h e ell down th e stairs an d developed a sign i can t
le t sh ou lder an d pectoral h em atom a. Th e x-rays taken at th at
tim e sh owed n o ractu re or displacem en t o th e prosth esis.

Fig 19.6-1a c Pre ope rative

situation of the le ft shoulde r with
a pronounce d arthritis.
a AP vie w.
b Late ral Ne e r vie w.
a b c c Axial vie w.

Fig 19.6-2a b Postope rative

im age s of the le ft total shoulde r
prosthe sis.
a AP vie w.
a b b Late ral Ne e r vie w.

401
 Se ct io n 3Case s
19.6 Implant
re movalinfe cte d
total
shoulde r
arthroplasty
Eigh t m on th s postoperatively th e patien t com plain ed o pain
at rest an d du rin g th e n igh t th at in creased w ith activities o
daily livin g. He presen ted w ith a le t prepectoral tu m e action
an d eryth em a ( Fig 19.6-3 ). A com pu ted tom ograph ic scan
sh ow ed n o sign s o osteolysis or prosth etic loosen in g bu t
dem on strated a pectoralis m ajor m u scle h em atom a w ith
several sm all collection s o gas ( Fig 19.6-4 ). A join t aspiration
w as per orm ed; th e f u id aspirated rem ain ed sterile.
a b
a b
a b c c
402
Th e clin ical exam in ation sh ow ed a relatively good le t
sh ou lder ran ge o m otion (ROM) w ith 110 active f exion
an d abdu ction , 30 extern al rotation , an d in tern al rotation
to L5. Th e stren gth w as con served bu t m ovem en t provoked
pain in th e rotator cu . Th e x-rays w ere n orm al ( Fig 19.6-5 ).
Th e C-reactive protein (CRP) level w as in creased at 72 m g/ L
an d th e patien t h ad n o ever.
Fig 19 .6 -3a b Erythe m a and pe ctoral
swe lling at the 10 -m onth follow-up.
Fig 19 .6 -4 a b Com pute d tom ographic
scans of the le ft shoulde r show volum inous
he m atom a unde r the pe ctoralis major
muscle . The arrow (a ) shows gas pocke ts that
are highly suspicious of infe ction.
Fig 19 .6 -5a c X-rays show le ft shoulde r
re place m e nt at the 10 -m onth follow-up.
a AP vie w.
b Late ral Ne e r vie w.
Axial vie w.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Arthur Grze siak, Alain Farron
2 In d ica t io n s
At 10 m on th s a ter th e le t total sh ou lder arth roplasty, th e
patien t n oted h is sh ou lder w as m ore pain u l an d presen ted
w ith clin ical sign s h igh ly su spiciou s or a low -grade in ection :
Pain at rest, w orse w ith m ovem en t
Posttrau m atic h em atom a le t pectoralis m ajor w ith gas
in th e so t tissu e
Eryth em a arou n d th e su rgical site an d th e h em atom a
Risin g CRP level
Low -grade in ection s cau sed by less viru len t organ ism s
o ten presen t w ith ew im pressive clin ical n din gs. Typical
sign s like im plan t loosen in g, osteolysis, or stu la can be
absen t or develop late, som etim es a ter years. A detailed
h istory an d h igh in dex o su spicion are m an datory, even
ah ead o n egative join t aspiration (w h ich can be alse
n egative in u p to 20% o cases).
Th e goals o th e proposed treatm en t are:
Iden ti cation o th e respon sible cau sative organ ism
an d establish its sen sitivities
De n itive con trol an d h ope u lly eradication o in ection
Pain ree an d satis actory sh ou lder u n ction to allow
th e patien t to con tin u e h is pro ession an d resu m e
activities o daily livin g
3 Pre o p e ra t ive p la n n in g
Th e respon sible organ ism s are u n iden ti ed an d th e sym ptom s
h ave lasted or m ore th an 3 w eeks. Addition ally, th e skin
con dition s are n ot calm . Th e au th ors decided to per orm a
tw o-stage exch an ge o th e prosth esis w ith a tem porary
spacer. Th e in terval betw een th e tw o operation s perm its
iden ti cation o th e organ ism , plan n in g th e an tibiotic th er-
apy, an d im provin g th e skin con dition s. Th e decision abou t
th e len gth o th e in terval is determ in ed a ter obtain in g th e
an tibiogram an d accordin g to th e local so t-tissu e situ ation .
Th e procedu re is per orm ed w ith th e patien t u n der gen eral
an esth esia in beach ch air position . An tibiotics, i given
be ore, sh ou ld be stopped m ore th an 2 w eeks be ore th e
operation to in crease th e ch an ces o iden ti yin g th e respon -
sible organ ism .
Th e su rgeon sh ou ld be prepared to deal w ith in traoperative
h u m eral sh a t ractu re an d h ave xation h ardw are ready,
su ch as plates or cables. Som etim es prosth etic com pon en ts
are so w ell xed th at a bon e w in dow or even an osteotom y
is n ecessary to explan t th em . Su rgeon s per orm in g pros-
th etic explan tation sh ou ld be am iliar w ith th ose tech n iqu es.
Su rgical debridem en t is per orm ed w ith scalpel or electro-
cau tery. Slotted-teeth cu rettes o di eren t sizes are advan -
tageou s, especially or bon e debridem en t.
I pre abricated spacers are u sed, th e su rgeon sh ou ld obtain
di eren t sizes to best m atch th e patien ts an atom y. I th e
su rgeon plan s to cu stom -m ake th e spacer, it is essen tial to
u se h eat-resistan t an tibiotic pow der, as th e polym eth yl-
m eth acrylate cem en t reach es a h igh tem peratu re du rin g
polym erization .
4 Su rgica l a p p ro a ch
Th e in terven tion is per orm ed th rou gh th e deltopectoral
approach w h ich o ers several advan tages:
Excellen t visibility o rotator cu , h u m eral h ead,
proxim al sh a t, glen oid
Distally exten sible i n ecessary
It is th e stan dard approach or total sh ou lder arth ro-
plasty
A su bscapu laris ten otom y allows good in traarticu lar exposu re
an d perm its easy displacem en t o th e h u m eral h ead an d
diaph ysis an teriorly.
5 Su rgica l d e b rid e m e n t
All n ecrotic tissu es, bon e ragm en ts, an d th e syn ovial m em -
bran es are debrided. Th e su rgeon m u st care u lly rem ove all
rem ain in g su tu res rom previou s su rgeries as th ey are oreign
bodies th at cou ld h arbor bacteria. Th e h u m eral diaph ysis is
clean ed w ith slotted-teeth cu rettes to rem ove th e brou s
tissu es o th e in ter ace betw een bon e an d im plan t. A ter
debridem en t th e wou n d is irrigated with 9 L o salin e solu tion
u sin g a pu lsatile lavage device.
In th is case th e su bscapu laris an d su praspin atu s ten don w ere
n ot ou n d in traoperatively.
403
 Se ct io n 3Case s
19.6 Implant
re movalinfe cte d
total
shoulde r
arthroplasty
6 Im p la n t re m o va l
Th e arth roplasty im plan t can be rem oved w ith stan dard
explan t system s. Som e m an u actu rers allow detach m en t o
th e prosth etic h ead rst. In th at w ay a special or u n iversal
extractor w ith a slidin g h am m er device can be con n ected
to th e stem . I th e su rgeon is n ot am iliar w ith th e com po-
n en ts in place, h e or sh e sh ou ld re er to th e m an u actu rer
or advice an d special explan t in stru m en ts. Th e rem oval o
th e prosth etic h ead o ers th e advan tage o allow in g direct
access to th e bon e-stem in ter ace. I th e stem is n ot retract-
able by sim ple h am m erin g w ith th e extractor, th e su rgeon
m u st ree th e bon e-im plan t in ter ace by u se o lexible
osteotom es, or ch isels betw een th em . Excessive orce can
create h u m eral sh a t ractu res, so con sider a con trolled sh a t
osteotom y i th e stem rem ain s solidly a xed to th e sh a t.
Th e cem en ted glen oid com pon en t can be rem oved w ith
stan dard osteotom es an d ch isels. In th is case th e glen oid
polyeth ylen e w as loosen ed an d rem oved by h an d. Th e su r-
geon sh ou ld rem ove all th e polym eth ylm eth acrylate cem en t
as it represen ts a oreign body, w h ich is typically covered
by bacterial bio lm .
Th e sam e prin ciple applies to cem en t arou n d prosth etic
stem s. In th is case th e h u m eral stem w as n ot cem en ted.
a b
404
All th e prosth etic com pon en ts w ere sen t or son ication . A
m in im u m o th ree tissu e sam ples w ere h arvested an d u n -
derw en t m icrobiological cu ltu res. Th en em piric an tibiotic
th erapy w as started in traven ou slyin th is case w ith 2.2 g
o coam oxicillin .
7 Te m p o ra r y fixa t io n
A cu stom -m ade spacer is orm ed w ith 40 g o PMMA cem en t
ch arged w ith su pplem en tary an tibiotics (2 g o van com ycin
an d 4 g o gen tam icin ). It is arm ed w ith a on e-th ird tu bu lar
plate to en h an ce its stability ( Fig 19 .6 -6 ). Th e im plan ted
spacer h elps to eradicate th e in ection by providin g local
an tibiotics in a m u ch h igh er con cen tration th an cou ld by
ach ieved w ith oral or in traven ou s an tibiotics. Mech an i-
cally, it protects th e so t tissu es rom retraction , w h ich cou ld
m ake a secon dary arth roplasty di cu lt an d allow s early
m obilization o th e lim b w h ich h elps to dim in ish m u scle
atroph y an d articu lar sti n ess.
Th e sh ou lder w as redu ced w ith th e spacer an d th e m obility
an d stability tested to en su re th at postoperative m obilization
w as possible. Th e su bscapu laris ten don w as su tu red an d th e
w ou n d closed layer by layer w ith n on resorbable sim ple
stich es.
Fig 19 .6 -6a b Postope rative vie ws of the
ce m e nte d space r.
a AP vie w.
b Late ral Ne e r vie w.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Arthur Grze siak, Alain Farron

8 Po s t o p e ra t ive m a n a ge m e n t Th e clin ical param eters an d th e organ ism s sen sitivity to

Th e postoperative m an agem en t con sists o a 4-w eek period
o im m obilization in a slin g an d sw ath -like com m ercial
sh ou lder im m obilizer. Postoperative x-rays (AP an d lateral
Neer view s) are taken to veri y th e spacer position an d
exclu de iatrogen ic ractu res ( Fig 19 .6 -6 ).
Han d, w rist, an d elbow are m obilized im m ediately. Sh ou lder
m obilization is started w h en pain con trol is satis actory,
avoidin g abdu ction an d f exion below 30 or 4 w eeks, th en
ree ROM is allow ed as tolerated.
In th is case, th e son ication an d tissu e sam ples cu ltu red
positive or Staphylococcus epidermidis. Accordin g to th e
an tibiogram ( Ta b le 19 .6 -1 ), coam oxicillin w as replaced by
f u cloxacillin 2 g every 6 h ou rs in traven ou sly or 2 w eeks,
ollow ed by cotrim oxazole 3 tim es per day orally u n til th e
im plan tation o th e n ew prosth esis.
Th e scar an d su rrou n din g so t tissu es rapidly dem on strated
a good resolu tion o in ection . Th e CRP dropped to n orm al
levels w ith in 2 w eeks.
ri am pin perm it a sh ou lder arth roplasty reim plan tation
a ter a sh ort in terval o 2 w eeks. In cases o rotator-cu
absen ce, th e su rgeon can im plan t a reverse total sh ou lder
prosth esis to ach ieve better m obility. I th is option is n ot
possible, an exch an ge o th e spacer or a h em iarth roplasty
is advan tageou s. Spacers can produ ce excessive glen oid w ear
over tim e becau se o its n on polish ed su r ace. Hem iarth ro-
plasty w ill n ot ach ieve a better u n ction com pared a spacer
bu t can sign i can tly redu ce w ear an d th e risk o secon dary
glen oid destru ction .
Becau se o qu ick pain relie an d satis actory u n ction o h is
sh ou lder, th e patien t in itially re u sed a secon d in terven tion .
Th e an tibiotic th erapy w as con du cted or a total o 3 m on th s
an d th en stopped. Th e sh ou lder rem ain ed asym ptom atic.
At th e 8-m on th ollow -u p th e patien t w as satis ed w ith h is
le t sh ou lder w ith on ly occasion al pain . Th e ROM w as lim -
ited w ith 90 f exion an d abdu ction , 10 extern al rotation ,
an d in tern al rotation to L5. Th e x-rays sh ow a w ell-position ed
spacer w ith ou t glen oid w ear ( Fig 19 .6 -7 ). At th at tim e, th e
patien t agreed to u n dergo a secon d-stage procedu re.

St a p h ylo co ccu s e p id e rm id is (8 x 10E2 germs/mL)

Antibiogram I
Penicillin G R
Oxacillin S
Flucloxacillin S
Amoxicillin R
Amoxicillin/clavulanic acid S
Gentamicin S
Tetracyclin S
Doxycyclin S
Erythromycin S
Clarithromycin S
Clindamycin S
Cotrimoxazole S
Ciprofloxacin S
Levofloxacin S
Rifampin S
Vancomycin S
Teicoplanin S
Fusidic acid R
1. Staphylococcus epidermidis a b
Ta b le 19.6-1 The antibiogram obtaine d afte r culture s of sonication Fig 19.6-7 a b The situation re m ains stable 10 m onths afte r space r
uid. Note the organisms se nsitivity to rifam pin. This is a good im plantation with no additional gle noid we ar.
prognostic factor.
Abbre viations: I, inte rme diate; N, not de ne d; R, re sistant; S, se nsitive .

405
 Se ct io n 3Case s
19.6 Implant
re movalinfe cte d
total
shoulde r
arthroplasty
9 Re im p la n t a t io n
Th e secon d stage w as per orm ed 10 m on th s a ter th e rst
stage. It con sisted o spacer rem oval an d placem en t o a
h em iarth roplasty.
Norm ally, th e secon d stage in clu des a m ajor debridem en t
bu t in th is case th e in ection w as con sidered to be resolved
or m ore th an 10 m on th s an d th e so t tissu es w ere calm .
Th e au th ors u sed stan dard an tibiotic proph ylaxis as or
prim ary arth roplasty w ith 1.5 g in traven ou s ce u roxim e 20
m in u tes be ore th e skin in cision w h ich w as con tin u ed u n til
n al m icrobiological cu ltu re resu lts.
Th e position in g o th e patien t w as iden tical to th e rst stage:
beach ch air position u n der gen eral an aesth esia. Th e sam e
deltopectoral approach w as u sed.
In th is case th e spacer w as rem oved by h an d w ith ou t an y
special in stru m en ts an d w as sen t or son ication .
Th e glen oid did n ot dem on strate excessive w ear. Th e h em i-
arth roplasty w as per orm ed ollow in g th e stan dard su rgical
tech n iqu e o th e m an u actu rer. An an atom ical, n on cem en t-
ed stem w as u sed.
a b
406
Wou n d closu re w as per orm ed in th e u su al w ay over an
in traarticu lar su ction drain , w h ich is n orm ally rem oved on
th e secon d day.
Postoperative x-rays (AP an d lateral Neer view s) to veri y
th e prosth esis position sh ow ed an iatrogen ic displaced
periprosth etic ractu re ( Fig 19.6-8 ). Th e au th ors decided to
treat it con servatively.
Th e postoperative m an agem en t con sisted 6 w eeks o im -
m obilization in a slin g an d sw ath e-like com m ercial sh ou lder
im m obilizer. Norm ally, h an d, w rist, an d elbow are m obilized
im m ediately an d sh ou lder m obilization is started w h en pain
con trol is satis actory, w ith active f exion an d abdu ction o
m axim u m 90 w ith ou t extern al rotation . Free m otion in all
direction s is allow ed a ter 6 w eeks.
In th is case sh ou lder m obilization w as delayed u n til th e
6-w eek ollow -u p visit, w h en x-rays con rm ed n o addi-
tion al displacem en t o th e ractu re.
Th e son ication f u id cu ltu res rem ain ed sterile an d ce u roxim e
w as stopped on postoperative day 5.
Fig 19 .6 -8a b X-rays take n on postope rative
day 1. Minim ally displace d pe riprosthe tic shaft
fracture .
a AP vie w.
b Late ral Ne e r vie w.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Arthur Grze siak, Alain Farron

10 Ou t co m e 12 Pe a rls

At 3-m on th ollow -u p, th e patien t w as asym ptom atic. Th e
le t sh ou lder ROM w as satis actory w ith 90 f exion , 80
abdu ction , 20 extern al rotation , an d in tern al rotation to
L5. In th e stren gth exam in ation , th e le t sh ou lder stren gth
w as sligh tly dim in ish ed in abdu ction an d in tern al rotation .
Th ese n din gs ref ected th e absen t su praspin atu s an d su b-
scapu laris ten don s.
I possible delay an tibiotic proph ylaxis u n til tissu e
sam ples or m icrobiology are h arvestedyou dim in ish
alse-n egative resu lts.
Make you r h an d-m ade spacer w ith a ben t K-w ire
distallyin case o spacer ractu re or in ten tion al
ragm en tation rem ove th e distal blocked parts w ith ou t
osteotom y.

Radiologically, th e ractu re is h ealin g n on displaced w ith

good callu s orm ation ( Fig 19.6-9 ).

11 Pit fa lls

Norm al skin f ora like Propionibacterium acnes or

S epidermidis provoke low -grade in ection s an d a
positive cu ltu re can be m isin terpreted as a con tam in a-
tion : correlate th e resu lts w ith th e clin ical h istory an d
presen tation .
Plan su rgical approach accordin g to th e w orst-case
scen ario. It sh ou ld be u sable or exten sile sh ou ld
som eth in g go w ron g, eg, in case o an in traoperative
ractu re or n eed or an osteotom y.

Fig 19 .6 -9a b Thre e m onths afte r

he m iarthroplasty. The pe riprosthe tic fracture
shows callus form ation and no se condary
displace m e nt.
a AP vie w.
a b b Late ral Ne e r vie w.

407
 Se ct io n 3Case s
19.6 Implant
re movalinfe cte d
total
shoulde r
arthroplasty

408 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Lisca Dritte nbass, Xavie r Cre voisie r, Mathieu Assal
19.7 Im p la n t re m o va la cu te ly in fe cte d to t a l a n kle
a rth ro p la s t y
Lisca Dritte nb ass, Xavie r Cre voisie r, Math ie u Assal
1 Ca s e d e s crip t io n
A 71-year-old w om an presen ted w ith a 2-w eek h istory o
in creasin g pain , redn ess, an d sw ellin g o h er le t an kle w ith
ever an d ch ills or th e past 36 h ou rs. Sh e h ad u n dergon e
total an kle arth roplasty 6 years be ore. Her on ly oth er per-
tin en t m edical h istory in clu ded recu rren t depression . Ph ysical
exam in ation revealed in creased w arm th , eryth em a, in du ra-
tion , an d ten dern ess abou t th e distal leg an d an kle. Skin
w as in tact w ith ou t drain age or abscess orm ation . Distal
pu lses w ere presen t, an d sen sation w as in tact in both low er
lim bs. Laboratory resu lts dem on strated w h ite blood cell cou n t
o 13,300 cells/ L, h em oglobin level 11.4 g/ dL, an d C-re-
active protein (CRP) level o 210 m g/ L. X-rays o th e le t
an kle sh ow ed radiolu cen cy arou n d th e tibial com pon en t
w ith cyst orm ation ( Fig 19.7-1 ). A ten tative diagn osis w as
m ade o acu te late periprosth etic join t in ection o th e le t
an kle arth roplasty.
a b
Fig 19.7-1 a b Pre ope rative x-rays of the le ft ankle show som e are as
of radioluce ncy around the tibial com pone nt with cyst formation.
a AP vie w.
b Late ral vie w.
2 In d ica t io n s
Becau se o th e presu m ed diagn osis, em ergen cy su rgical treat-
m en t w as in dicated w ith ou t prior aspiration o th e join t du e
to th e critical clin ical situ ation o an acu tely ill, ebrile patien t
w ith u n stable blood pressu re. Sin ce preoperative x-rays
sh ow ed periprosth etic bon e resorption an d bon e cysts,
reten tion o th e com pon en ts w as n ot recom m en ded. Th e
su rgical plan w as or a tw o-stage procedu re w ith u rgen t
debridem en t, rem oval o all com pon en ts, placem en t o a
gen tam icin -loaded cem en t spacer, an d tem porary extern al
xation as a rst step. A on e-stage procedu re con sistin g o
irrigation , debridem en t, polyeth ylen e exch an ge, an d reten tion
o th e im plan ts w as n ot an option du e to x-ray eviden ce o
im plan t loosen in g.
Eigh t w eeks a ter th e in itial procedu re n al recon stru ction
in clu ded rem oval o th e spacer an d extern al xator w ith an
an kle arth rodesis by m ean s o an in terposition iliac crest
corticocan cellou s bon e gra t an d xation w ith screw s an d
an terior plate. Th e in dication or an arth rodesis w as based
on a patien t w ith a seden tary li estyle an d low u n ction al
dem an ds w h o w as seekin g a perm an en t solu tion an d n ot
opposed to sacri cin g join t m obility. Revision arth roplasty
w as con sidered to carry a h igh er risk o n eedin g u rth er
su rgery in th e u tu re an d w as th ere ore n ot proposed.
Th e literatu re to ou r kn ow ledge does n ot cu rren tly provide
a stan dardized algorith m or treatm en t o prosth etic join t
in ection o th e total an kle. Fu rth erm ore, it is n ot clear
w h eth er algorith m s allow in g sh ort in tervals or tw o-stage
procedu res or in ected arth roplasty o th e kn ee an d th e h ip
can be sa ely applied to th e an kle. Th e lon g in terval o 8
w eeks betw een stages w as allow ed or 6 w eeks o cu rative
an tibiotic treatm en t ollow ed by an an tibiotic- ree in terval
o 2 w eeks prior to th e n al recon stru ction .
409
 Se ct io n 3Case s
19.7
Implant
removalacute ly
infe cte d
total
ankle
arthroplasty
3 Pre o p e ra t ive p la n n in g
Rem oval o th e im plan t requ ired th e n ecessary in stru m en ta-
tion , in clu din g specially sh aped ch isels. Th e patien t w as
position ed su pin e w ith a pad u n der th e ipsilateral bu ttock
to position th e ore oot poin tin g to th e ceilin g ( Fig 19 .7-2 ).
No tou rn iqu et w as u sed. In traven ou s an tibiotics w ere ad-
m in istered in traoperatively a ter all m icrobiological sam ples
were obtain ed. Th e patien t was placed u n der gen eral an esth esia
in th e settin g o acu te in ection a ectin g th e lim b.
For th e secon d-stage in terven tion th e sam e protocol w as
applied except or th e u se o a th igh tou rn iqu et.
Fig 19.7-2 The patie nt was positione d supine with a pad unde r the
ipsilate ral buttock to position the fore foot pointing to the ce iling.
A tournique t was applie d but not in ate d.
Fig 19.7-3 Ante rior approach to the ankle .
410
4 Su rgica l a p p ro a ch a n d d e b rid e m e n t
An an terior approach to th e an kle w as m ade th rou gh th e
existin g an terior m idlin e in cision , exten din g rom 810 cm
proxim al o th e join t lin e dow n to th e lateral aspect o th e
talon avicu lar join t ( Fig 19.7-3 ). Follow in g th e skin in cision ,
su bstan tial pu ru len t liqu id w as n oted. Th e exten sor reti-
n acu lu m w as exposed w h ile care u lly protectin g th e m edial
bran ch o th e su per cial peron eal n erve in th e distal portion
o th e in cision du rin g su bcu tan eou s dissection . Splittin g o
th e retin acu lu m w as per orm ed an d th e join t capsu le w as
accessed th rou gh th e in terval betw een th e tibialis an terior
ten don m edially an d th e exten sor h allu cis lon gu s laterally.
In traoperative statu s revealed pu s in th e an kle join t space
w ith stable im plan ts. Th e n eu rovascu lar bu n dle con sistin g
o th e an terior tibial artery an d th e deep peron eal n erve w as
iden ti ed in th e proxim al portion o th e in terval an d retracted
laterally. Th e at tissu e on th e join t capsu le w as in cised u sin g
ligatu res or th e tran sverse vessels crossin g th is area.
A ter th orou gh irrigation an d debridem en t, all n ecrotic an d
brotic so t tissu e w as m eticu lou sly rem oved. All devitalized
an d septic tissu es w ere rem oved by u se o a Lu er ron geu r.
Th e an terior rim o th e tibia w as sparin gly rem oved to u lly
expose th e im plan t ( Fig 19.7-4 ). Cysts above th e tibial im plan ts
w ere revealed. Pu ru len t f u id an d six tissu e sam ples w ere
retrieved or m icrobiological an d h istological testin g. Em piric
in traven ou s an tibiotic treatm en t w as in itiated w ith coam oxi-
cillin a ter obtain in g all sam ples.
Fig 19.7-4 Cysts above the tibial im plant.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Lisca Dritte nbass, Xavie r Cre voisie r, Mathieu Assal
5 Im p la n t re m o va l
Th e polyeth ylen e com pon en t w as rem oved w ith Koch er
orceps. Di eren t size ch isels w ere u sed arou n d th e tibial
an d talar im plan ts to acilitate th eir rem oval ( Fig 19 .7-5 ).
Fibrotic tissu e u n dern eath th e rem ain in g bon e su r ace w as
rem oved th orou gh ly an d abu n dan t rin sin g w ith an an tiseptic
polyh exan ide solu tion w as per orm ed u sin g a pu lsatile
jet-lavage irrigation system .
Fig 19.7-5 Im plant re m oval using diffe re nt size chise ls around the
tibial and talar im plants.
a b
Fig 19.7-6 a b A m e dial tibiocalcane onavicular e xte rnal xator was
applie d to achie ve te m porary stabilization of the ankle .
a AP vie w.
b Late ral vie w.
6 Te m p o ra r y fixa t io n
A h igh -viscosity gen tam icin -loaded polym eth ylm eth acrylate
(PMMA) spacer w as m olded to ll th e cavity. Th e w ou n d
w as closed prim arily over tw o drain s. A m edial tibiocalca-
n eon avicu lar extern al xator was applied to ach ieve tem porary
stabilization o th e an kle w ith ou t com prom isin g access to
th e w ou n d or requ en t dressin g ch an ges ( Fig 19.7-6 ).
7 Po s t o p e ra t ive m a n a ge m e n t (1)
Postoperative x-rays are sh ow n in Fig 19.7-7 . Th e drain s w ere
rem oved w ith in 48 h ou rs postoperatively, an d th e dressin gs
w ere ch an ged daily u n til th e w ou n d w as dry. Th e extern al
xator w as le t in place or 8 w eeks u n til th e secon d in ter-
ven tion was per orm ed. Th e patien t was m obilized w ith partial
weigh t bearin g o 15 kg or th e en tire period. Microbiological
sam ples revealed in ection w ith m eth icillin -sen sitive Staphy-
lococcus aureus, an d treatm en t was con tin u ed w ith f u cloxacil-
lin 4 x 2 g in traven ou sly daily or 14 days. Ri am pin 2 x 450
m g in traven ou sly daily w as added a ter th e w ou n d h ad be-
com e com pletely dry. A ter 2 w eeks th e patien t w as disch arged
an d an tibiotic treatm en t w as con tin u ed w ith ciprof oxacin
2 x 750 m g per day orally an d ri am pin 2 x 450 m g per day
orally or 4 w eeks. All an tibiotics w ere discon tin u ed 2 w eeks
be ore th e secon d su rgery.
a b
Fig 19.7-7 a b Postope rative x-rays afte r im plant re m oval show the
cavity lle d with a ce m e nt space r and stabilization with an e xte rnal
xator.
a AP vie w.
b Late ral vie w.
411
 Se ct io n 3Case s
19.7
Implant
removalacute ly
infe cte d
total
ankle
arthroplasty

8 An k le a r t h ro d e s is 9 Po s t o p e ra t ive m a n a ge m e n t (2)

Eigh t w eeks a ter th e rem oval o th e in ected im plan t th e Postoperative x-rays are sh ow n in Fig 19 .7-8 . In traven ou s
n al recon stru ction w as per orm ed. Th is con sisted o rem oval an tibiotics w ere con tin u ed u n til n al h istology an d bacte-
o th e extern al xator an d PMMA spacer, ollow ed by tib- riology revealed n o in ection . No u rth er an tibiotics w ere
iotalar arth rodesis. Preoperative laboratory resu lts h ad adm in istered. A low er-leg split com bicast w as u sed or post-
revealed regression o th e CRP level to 5 m g/ L an d w h ite operative im m obilization . Th e patien t rem ain ed n on w eigh t
blood cell cou n t to 7,300 cells/ L. bearin g or 6 w eeks an d th en began partial w eigh t bearin g
w ith in creasin g w eigh t or an addition al 4 w eeks w ith a
Th e operation started with rem oval o th e extern al xator. low er-leg com bicast boot or a u rth er 8 w eeks.
Th e previou s an terior approach to th e an kle join t w as u sed
an d th e PMMA spacer w as rem oved revealin g a clean an kle
cavity. Six tissu e sam ples w ere obtain ed or m icrobiological
exam in ation ollow in g w h ich a gen eral proph ylactic an ti-
biotic (ce u roxim e 1.5 g) w as adm in istered in traven ou sly.
Th orou gh debridem en t an d irrigation w ere per orm ed, an d
a 1 m m layer o bon e w as rem oved to obtain a clean bon e
su r ace.

Th ree large corticocan cellou s stru ts w ere h arvested rom

th e ipsilateral an terior iliac crest. Next an obliqu e bu lar
osteotom y w as per orm ed th rou gh a direct lateral approach
7 cm proxim al to th e tip o th e lateral m alleolu s. A 7 m m
slice w as rem oved an d th e rem ain in g edges w ere m ade
sm ooth . Th e m edial th ird o th e bu la w as rem oved w ith
an oscillatin g saw . Th e bon e gra t stru ts w ere placed in a
m an n er to span th e cavity betw een th e tibia an d th e talu s
an d xed w ith tw o can n u lated 4.0 m m screw s. On e screw a b
w as placed rom posterolateral aim in g rom proxim al to
Fig 19.7-8 a b Postope rative x-rays afte r ankle arthrode sis.
distal an d on e rom lateral begin n in g in th e lateral process a AP vie w.
o th e talu s aim in g proxim ally. Th e an kle w as m ain tain ed b Late ral vie w.
in n eu tral position . Th e rem ain in g bu la w as xed to th e
tibia w ith on e 3.5 m m cortical screw . To au gm en t stability
a con tou red recon stru ction plate w as applied an teriorly an d
xed w ith ve screw s. Th e w ou n d w as closed over a drain
layer by layer w ith n on absorbable su tu res or th e skin .

412 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Lisca Dritte nbass, Xavie r Cre voisie r, Mathieu Assal

10 Ou t co m e 11 Pit fa lls

All w ou n ds h ealed u n even t u lly. At 6 m on th s th e patien t Delayed or m issed diagn osis o in ection
presen ted w ith a f u id gait an d on ly occasion al pain . Clin i- Wron g strategy or rem oval o im plan ts
cally, th e an kle rem ain ed in a w ell-align ed n eu tral position . Rem ovin g too m u ch bon e stock
X-rays at 6 m on th s dem on strated solid u n ion w ith n o sign s Failin g in adequ ate debridem en t o con tam in ated bon e
o gra t resorption or in ection , an d at 2 years th ey rem ain ed an d so t tissu es
u n ch an ged ( Fig 19 .7-9 ). Th e patien t w as h igh ly satis ed w ith Su rgical w ou n d breakdow n
th e ou tcom e w ith n o pain or lim itation in h er daily
activities.
12 Pe a rls

An y prosth etic join t th at becom es pain u l w ith an

elevated CRP level sh ou ld raise su spicion o in ection ;
appropriate steps sh ou ld be taken to con rm or ru le
ou t in ection .
Appropriate preoperative plan n in g is m an datory an d
in clu des:
Iden ti cation o im plan ts
Approach
In stru m en ts or im plan t rem oval an d bon e
debridem en t
Per ect kn ow ledge o im plan t revision or tibiotalar
u sion tech n iqu es
Th is w ill m in im ize bon e loss an d im prove th e post-
operative u n ction al resu lt.
Su rgical w ou n d com plication s can be m in im ized w ith
a b good su rgical tech n iqu e (m in im izin g dissection an d
gen tle so t-tissu e h an dlin g) an d appropriate post-
Fig 19.7-9 a b X-rays at 2 ye ars de m onstrate d solid union with no
signs of graft re sorption or infe ction.
operative im m obilization w ith stable extern al xation .
a AP vie w. Treatm en t o prosth etic join t in ection requ ires a team
b Late ral vie w. approach specialized in th is eld. Th is w ill su bstan tially
im prove h ealin g rates an d ou tcom es.

413
 Se ct io n 3Case s
19.7
Implant
removalacute ly
infe cte d
total
ankle
arthroplasty

414 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Anjan P Kaushik, John C Elfar
19.8 Im p la n t re m o va lch ro n ica lly in fe cte d to t a l
e lb o w a rth ro p la s t y
An jan P Kau shik, Joh n C Elfar
1 Ca s e d e s crip t io n
A 72-year-old le t-h an ded w om an u n derw en t sem icon -
strain ed cem en ted righ t total elbow arth roplasty (TEA) at
an oth er in stitu tion 15 years prior to presen tation . Sh e
developed a deep in ection 13 years a ter th e origin al su rgery
an d u n derw en t im plan t rem oval an d debridem en t th at
in clu ded radial h ead resection , an d sin gle-stage im m ediate
reim plan tation o a sem icon strain ed TEA w ith an tibiotic-
im pregn ated cem en t. Microbiology reports o cu ltu res rom
th e secon d procedu re dem on strated grow th o m eth icillin -
resistan t Staphylococcus aureus (MRSA). Fig 19 .8 -1 a c display
th e elbow x-rays 2 years a ter on e-stage revision an d
presen tation to th e au th ors in stitu tion . Lytic areas adjacen t
to th e cem en t in ter ace prom pted a com pu ted tom ograph ic
scan , w h ich dem on strated u rth er lu cen cies arou n d th e
im plan t ( Fig 19 .8 -1d e ).
a b
Fig 19.8-1a e Pre ope rative im age s of the right e lbow.
a AP vie w.
b Oblique vie w.
c Late ral vie w.
d e Com pute d tom ographic scans (axial cuts).
Th e patien t con tin u ed to h ave sym ptom s, w h ich in clu ded
lim ited ran ge o m otion (ROM), persisten t edem a, eryth em a
o th e elbow join t, an d pain w ith u se o th e righ t elbow .
Th e previou s in cision w as w ell h ealed, w ith ou t an y sin u s
tracts or drain age. Laboratory stu dies revealed an elevated
eryth rocyte sedim en tation rate (ESR) o 65 m m / h an d C-
reactive protein (CRP) level o 18 m g/ L. Repeated elbow
aspiration dem on strated th e presen ce o MRSA in ection
on cu ltu re. Th e patien t also h ad a h istory o bilateral total
kn ee an d bilateral total h ip arth roplasties. Her le t h ip
arth roplasty h ad been revised or aseptic loosen in g 7 years
be ore.
Treatm en t option s or th is patien t w ith ch ron ically in ected
TEA were discu ssed with h er, in clu din g resection arth roplasty,
tw o-stage com pon en t rem oval an d later reim plan tation ,
an d lon g-term an tibiotic su ppression . A ter discu ssion w ith
h er prim ary ph ysician an d an in ectiou s diseases specialist
or preoperative m edical optim ization , con siderin g h er
exten sive m edical h istory, sh e elected to u n dergo exten sive
debridem en t an d resection arth roplasty.
e
415
 Se ct io n 3Case s
19.8
Implant
removalchronically
infe cte d
total
e lbow
arthroplasty
2 Ba ck gro u n d : e t io lo gie s a n d ris k fa ct o rs
Man agem en t o TEA com plicated by in ection can be ch al-
len gin g, an d ailu re to eradicate th e cau sative path ogen s
m ay n ecessitate resection arth roplasty. In ection rates a ter
prim ary TEA h ave been reported to be in th e ran ge o 38%
[1 6 ], bu t on e series dem on strated rates u p to 12% [7 ].
Im provem en ts in su rgical tech n iqu e an d im plan ts, particu -
larly th e rou tin e u se o an tibiotic-im pregn ated cem en t an d
avoidan ce o postoperative h em atom as, h ave redu ced th e
in ciden ce o periprosth etic in ection s [3, 8].
Con tribu tin g actors to in ection in clu de th e th in so t-tissu e
en velope arou n d th e elbow, previou s procedu res to th e elbow,
prior in ection s, in f am m atory arth ritides (rh eu m atoid arth ritis:
adu lt an d ju ven ile orm s), an d im m u n ocom prom ised h ost,
wh ich o ten resu lts rom treatm en t with disease-m odi yin g
an tirh eu m atic dru gs (DMARDs) or steroids [5, 911]. Rh eu -
m atoid patien ts given exten sive dru g regim en s con sistin g o
n on steroidal an tiin f am m atory dru gs (NSAIDs), steroids an d
DMARDs are at risk or im m u n osu ppression , w h ich can ad-
versely a ect su rgical ou tcom e [12]. A recen t system atic review
[8] h as in dicated con cern over th e recen t rise in in ection s
secon dary to DMARD u se. Delayed wou n d h ealin g an d pro-
lon ged postoperative wou n d drain age, as well as reoperation
are also sign i can t risk actors or in ection [810, 13].
Revision or com plex elbow su rgery is also associated w ith
h igh er in ection rates. In on e series [1 4 ], 3 (23% ) o 13
patien ts w h o u n derw en t con version o a spon tan eou sly u sed
or an kylosed elbow to TEA h ad in ection s. In ection rates
or TEA per orm ed or posttrau m atic cau ses su ch as distal
h u m eral ractu res h ave been variable, ran gin g rom 12%
[15, 16] u p to 56% [1, 17, 18]. Selected in dication s or TEA
in th e settin g o trau m a sh ow a m u ch h igh er in ciden ce o
in ection -related ailu re, as is th e case w ith gu n sh ot w ou n ds
resu ltin g in com m in u ted ractu res arou n d th e elbow , w h ich
h ave a ailu re rate o 28% du e to deep in ection [19].
Patien ts w ith h em oph ilia u n dergoin g TEA m ay also be at
risk or periprosth etic in ection , alth ou gh on ly a sm all series
[20] h as been reported to date, in w h ich 1 (14% ) o 7 ar-
th roplasties becam e in ected. Total elbow arth roplasties in
patien ts you n ger th an 40 years w ere n ot ou n d to in crease
th e rate o in ection sign i can tly: 2 (4% ) o 55 cases h ad
deep in ection in on e series [21]. Obese patien ts (body m ass
in dex > 30) h ave a h igh er TEA revision rate th an n on obese
patien ts, h ow ever, th e im plan t su rvival rate or deep in ec-
tion w as sim ilar betw een th ese grou ps [22 ].
416
3 In d ica t io n s : e lb o w re s e ct io n a r t h ro p la s t y
Prin ciples or su rgical treatm en t acqu ired rom prosth etic
join t in ection s in total h ip an d total kn ee arth roplasties
m ay be applicable to th e elbow [8, 23, 24]. In th e treatm en t
algorith m proposed by Bern ard Morreys grou p [25] at th e
Mayo Clin ic, th e m ost sign i can t actors a ectin g ou tcom e
or revision arth roplasty or in ection in clu de du ration o
sym ptom s, patien t h ealth statu s, bacteriology, com pon en t
xation , bon e stock, an d care u l su rgical tech n iqu e.
In th e case presen ted, th e in dication or resection arth roplasty
in clu ded ch ron ic in ection w ith a h igh ly viru len t organ ism
(MRSA), w h ich h ad ailed prior on e-stage revision w ith
an tibiotic-im pregn ated cem en t. Moreover, th e lon g-term
presen ce o th e in ection w as a actor. Most patien ts w ith a
lon g-term in ection in a total join t arth roplasty are treated
w ith tw o-stage revision . Th is patien t w ith a lon g-term
in ection w ith a resistan t organ ism is n ot alw ays a can didate
or reim plan tation . Su ch patien ts sh ou ld be in orm ed th at
reim plan tation is n ot alw ays possible. Th is patien ts ragile
m edical statu s also avored an attem pt to per orm a sin gle
procedu re in stead o m u ltiple su rgeries. Fu rth erm ore, th e
presen ce o presu m ably u n in ected h ip an d kn ee arth roplasties
raises th e possibility th at a ch ron ic in ection in on e part o
th e body m ay even tu ally seed th ose u n in volved sites. For
th is reason , lon g-term su ppressive an tibiotics w ere n ot
avored.
Th e m ost com m on treatm en t option or ch ron ic TEA in ec-
tion s is resection arth roplasty bu t i th e patien t can n ot
tolerate su rgery, ch ron ic su ppressive an tibiotics can be
adm in istered in de n itely [9, 10]. Resection arth roplasty m ay
be th e best salvage treatm en t in patien ts w h o h ave low
u n ction al dem an ds or w h o can n ot m edically u n dergo m u l-
tiple exten sive su rgeries. Th e goals o su rgery are to o er
pain relie an d to m ain tain adequ ate ROM w ith stability.
Resection arth roplasty n eed n ot be a n al solu tion , as th e
decision to proceed to a secon d-stage revision procedu re
can be m ade at a later date. Con su ltation w ith th e in ectiou s
diseases specialist is recom m en ded. Th e treatm en t regim en
o th e in ection in clu ded 6 m on th s o an tibiotic treatm en t.
A ter th is period, eradication o th e in ection is con rm ed
w ith a bon e biopsy rom th e operative site prior to th e
con sideration o reim plan tation .
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Anjan P Kaushik, John C Elfar
4 Pre o p e ra t ive p la n n in g a n d w o rku p
Preoperative im agin g w ith AP, lateral, an d obliqu e elbow
x-rays sh ou ld be com pleted to evalu ate i th e com pon en t
xation is stable or loose, an d to exam in e th e exten t o
cem en t pen etration . Com pu ted tom ograph y m ay also assist
in determ in in g stability. Exam in ation sh ou ld ocu s on th e
patien ts n eu rological statu s, elbow stability, ROM, an d active
m u scle u n ction , particu larly active triceps m otor u n ction .
A com plete blood cou n t, ESR, an d CRP sh ou ld also be ob-
tain ed, w ith th e CRP level servin g as a baselin e w ith w h ich
to tren d th e resolu tion o in ection postoperatively [9, 25 ,
2 6 ]. An attem pt to obtain preoperative cu ltu res rom th e
elbow join t sh ou ld be com pleted w ith n eedle aspiration .
Diagn ostic in dication s o an in ected elbow arth roplasty in -
clu de presen ce o a sin u s tract an d w ou n d drain age, persisten t
join t in f am m ation or pain sym ptom s m ore th an 30 days,
radiograph ic eviden ce o loosen in g, abn orm al laboratory
valu es, an d a cu ltu re positive or an organ ism on aspiration
[26].
Th e su rgeon sh ou ld obtain operative reports rom th e prim ary
TEA an d oth er su bsequ en t procedu res, an d sh ou ld h ave
details o th e im plan ts an d cem en t tech n iqu e u sed. Speci c
atten tion sh ou ld be given to th e disposition o th e u ln ar
n erve an d to th e cem en t tech n iqu e u sed, w h ich presen t
critical elem en ts o th e operative plan . Previou s cu ltu re re-
su lts are also h elp u l. In th e operatin g room , th e availability
o a h igh -speed bu rr, osteotom es, cu rettes, im plan t-speci c
extraction in stru m en tation , pu lsatile lavage, an d an tibiotic
cem en t sh ou ld be con rm ed.
In traoperative m edication m an agem en t in rh eu m atoid
patien ts takin g DMARDs an d oth er an tiin f am m atories m ay
ollow th e gu idelin es detailed by How e an d colleagu es [12].
As ar as du ration o su rgery, in th e au th ors experien ce, 2
h ou rs are typically allow ed or revision o a loose prosth esis
an d u p to 2 addition al h ou rs allow ed or each com pon en t
th at is believed to be w ell xed. Th is m ean s th at th is exam ple
case w as booked or 4 h ou rs or resection arth roplasty.
5 Su rgica l a p p ro a ch
A posterior triceps-sparin g approach , as detailed by Bryan
an d Morrey [27], is com m on ly u sed. Th e u se o a sterile tou r-
n iqu et is appropriate bu t exsan gu in ation with a com pressive
Esm arch ban dage is discou raged to avoid th e possibility o
dissem in ation o in ectiou s m aterial rom th e join t. Tou rn iqu et
u se is con n ed to 2 h ou rs, with th e rst 90 m in u tes allowed
du rin g th e begin n in g o th e case an d th e n al 30 m in u tes
reserved or an y n ew cem en t im plan tation an d closu re over
a drain . For th e stan dard approach , a m idlin e in cision is m ade
th rou gh th e scar o th e previou s su rgery, an d m eticu lou s
so t-tissu e h an dlin g is em ph asized, with th e elevation o th ick
m edial an d lateral f aps an d avoidan ce o skin pin ch in g w ith
orceps. Sin u s tracts sh ou ld be excised. Exten sion o th e prior
in cision is o ten n ecessary in both th e proxim al an d distal
direction s to gain addition al exposu re. Th e u ln ar n erve is
reed an d retracted m edially, an d th e posterom edial triceps
is ref ected su bperiosteally, m ain tain in g con tin u ity w ith th e
orearm ascia [9, 25, 27]. All e orts to preserve or reattach th e
triceps in sertion sh ou ld be m ade. Fu rth er so t-tissu e releases
are com pleted u n til th e previou sly placed im plan ts are u lly
visu alized. An y f u id rem ain in g in th e join t an d loose con -
n ective tissu e or pseu dom em bran es in tim ately associated
w ith th e im plan t sh ou ld be sen t or m icroscopic exam in ation
an d cu ltu res with an tibiotic sen sitivity testin g.
6 Su rgica l d e b rid e m e n t a n d im p la n t re m o va l:
in t ra o p e ra t ive s t e p s
A th orou gh su rgical debridem en t o th e so t tissu es sh ou ld
be com pleted, an d specim en s sh ou ld be sen t or cu ltu res as
w ell as rozen -section path ology. In equ ivocal cases, su ch
as th ose w ith n o grow th on preoperative aspiration cu ltu res,
exam in ation by th e path ologist can be h elp u l or su rgical
decision m akin g [28 ].
Rem oval o loose im plan ts is gen erally straigh t orw ard, w ith
im plan t-speci c in stru m en ts or extraction . Th e bu sh in g
an d pin con n ectin g th e h u m eral com pon en t to th e u ln ar
com pon en t sh ou ld be rem oved, ollow ed by th e u ln ar
com pon en t i it is loose. Th e h u m eral com pon en t can th en
be extracted w ith th e appropriate clam p i it is loose. Th e
com pon en ts, cem en t ragm en ts, an d pseu dom em bran es
associated w ith th e im plan ts sh ou ld all be rem oved w ith th e
u se o osteotom es, cu rettes, ron geu rs, a m otorized rou ter,
an d a h igh -speed bu rr i th is is possible [9 , 2 6 ]. Creatin g a
sm all w in dow in th e posterior cortex o th e distal h u m eru s
can stream lin e th e rem oval process; h ow ever, m ain tain in g
417
 Se ct io n 3Case s
19.8
Implant
removalchronically
infe cte d
total
e lbow
arthroplasty
th e stru ctu ral in tegrity o th e h u m eral sh a t an d distal
h u m eral con dyles is im portan t or stability in a resection
arth roplasty [9 ]. A n ylon bru sh can be in serted in to th e
m edu llary cavities by h an d or as an attach m en t to th e pu l-
satile lavage [26 ]. In traoperative im age in ten si cation can
be u sed to localize cem en t ragm en ts deeper in th e can al
th at n eed to be retrieved. All attem pts sh ou ld be m ade to
preserve bon e stock du rin g th e cem en t extraction an d join t
debridem en t. Th is is becau se th e in tegrity o th e sh a t o th e
h u m eru s an d th e proxim al u ln a are in tegral to th e u n ction
o th e orearm . Sacri ce o th e h u m eral sh a t in particu lar
is discou raged.
Well- xed im plan ts, on th e oth er h an d, pose a sign i can t
tech n ical ch allen ge in revision arth roplasty, an d osteotom ies
o th e h u m eru s or u ln a are occasion ally n ecessary. In th e
case presen ted, th e u ln ar com pon en t w as loose an d w as
easily rem oved. Th e h u m eral com pon en t, h ow ever, w as
w ell xed; th ere ore, a 4 cm lon g x 1 cm w ide posterior
h u m eral trapezoidal osteotom y w as com pleted w ith oste-
otom y o th e lateral epicon dyle, as depicted in Fig 19 .8 -2 .
2x
x
Fig 19.8-2 Oste otomy of the poste rior hum e ral corte x for im prove d
e xposure during e xplantation of the hum e ral com pone nt.
Adapte d from Che ung e t al [9 ].
418
Plan n in g th e len gth o a h u m eral osteotom y is im portan t,
so i reim plan tation is ch osen in u tu re, a revision h u m eral
stem w ill bypass th e osteotom ized w in dow by tw o cortical
diam eters proxim ally [9, 25]. On th e u ln ar side, a lon gitu din al
osteotom y on th e proxim al m edial part o th e u ln a can o er
exposu re to slide f exible osteotom es distally to extract th e
im plan t. A pen cil-tipped bu rr can th en be passed in to th e
u ln ar m edu llary cavity to rem ove cem en t ragm en ts [9]. In
both th e h u m eral an d u ln ar osteotom ies, th e cortical win -
dow s sh ou ld be preserved or bon e stock to be later repaired
to th e h u m eru s or u ln a w ith su tu re or cerclage xation [25].
Resorbable su tu res or repair are pre erred over cerclage
w ires. Particu larly du rin g osteotom y steps, th e radial n erve
sh ou ld be protected alon g th e h u m eru s an d th e u ln ar n erve
alon g th e u ln a.
A ter exten sive debridem en t o th e bon e, so t tissu e, an d
cem en t, pu lsatile irrigation is th en com pleted w ith n orm al
salin e. An an tibiotic-im pregn ated cem en t spacer or cem en t
beads can be placed. Th ese are placed as ar in to th e m edu llary
can als o th e h u m eru s an d u ln a as possible. An tibiotics com -
m on ly u sed in clu de van com ycin an d tobram ycin . Beads can
be lin ked by absorbable su tu re or by stain less steel w ire an d
allow m ore su r ace area or elu tion o th e an tibiotics [9, 2 6].
In patien ts or w h om a resection arth roplasty is con sidered
a possible en d poin t, bead- or cem en t-based elu tion o an -
tibiotics can be problem atic. Th e triceps m u scle, ascia, an d
skin f aps sh ou ld be h an dled m eticu lou sly an d closed w ith
m on o lam en t su tu res to redu ce th e ch an ces o rein ection .
Closed circu it drain su ction is com m on ly u sed to redu ce th e
in ciden ce o h em atom a orm ation .
For resection arth roplasty, u ln oh u m eral stability is m ain ly
ach ieved by preservin g, i possible, th e m edial an d lateral
h u m eral con dyles, w ith w h ich th e residu al olecran on ar-
ticu lates [25]. Th ese con dyles can be deepen ed an d con tou red
to accom m odate th e proxim al u ln a as an articu lation [9]. In
som e in stan ces, on e or both con dyles m u st be rem oved to
rem ove th e im plan t, as in th e presen t case. In su ch a situ -
ation , th e con dyle(s) can be reim plan ted i th e bon e is viable.
How ever, in som e in stan ces bon e destru ction in th e settin g
o in ection can resu lt in n on viable bon e in th e con dyles
an d m ay becom e a sou rce o persisten t in ection . In th is
case, th e lateral con dyle w as rem oved as part o th e oste-
otom y to rem ove th e w ell- xed h u m eral stem . It w as partially
reim plan ted to bolster th e m edial con dyle an d to act as a
bu ttress again st m edial su blu xation o th e orearm in th e
postoperative period. Th e m edial colu m n w as le t in tact.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Anjan P Kaushik, John C Elfar
7 Po s t o p e ra t ive m a n a ge m e n t
Postoperatively, th e elbow is im m obilized in exten sion an d
th e drain can be rem oved w ith in 12 days, a ter ou tpu t
dim in ish es to less th an 20 m L every 8 h ou rs. Cu ltu res are
ollow ed or speciation , an d an in ectiou s diseases con su lta-
tion is m ade or appropriate an tibiotic selection accordin g
to sen sitivities. An in -h ospital n u trition ist con su ltation can
also be h elp u l or w ou n d h ealin g.
In traven ou s an tibiotics are m ain tain ed or at least 6 w eeks,
an d serial com plete blood cou n t, ESR, an d CRP serological
levels are draw n to m on itor or resolu tion o in ection an d
in f am m ation [9, 25]. In cases w h ere in ection does n ot resolve
via clin ical sym ptom s, serological m arkers, or reaspiration ,
a repeated irrigation an d debridem en t m ay be per orm ed
[26]. I th e patien t can n ot m edically tolerate addition al pro-
cedu res, lon g-term su ppressive an tibiotics m ay be th e on ly
rem ain in g option .
a b
Fig 19.8-3 a c Postope rative x-rays of the right e lbow.
a AP vie w.
b Oblique vie w.
c Late ral vie w.
8 Ou t co m e
Th is particu lar case was selected becau se o th e lon g-term
h istory o an in ection th at w as di cu lt to treat. Th e patien t
u n derwen t resection arth roplasty with ou t com plication . Post-
operative x-rays are sh ow n in Fig 19.8-3 . Th e idea o possible
reim plan tation in u tu re w as le t open . Most patien ts with
an in ected TEA seek a plan tow ard reim plan tation as soon
as possible. Every e ort sh ou ld be u n dertaken to u n derstan d,
in con su ltation w ith th e in ectiou s diseases specialist, th e
du ration o postresection an tibiotics th at w ill be n ecessary to
eradicate th e in ection . Even a ter th is period, w h ich in th is
case w as predicted to be 6 m on th s, u rth er diagn ostic testin g
is n ecessary to prove th at th e in ection was in deed u lly treated.
It is on ly based on th e resu lts o addition al testin g with open
or gu ided biopsy th at th e possibility o reim plan tation can be
visited. As a resu lt o th ese con sideration s, in th e au th ors'
practice, th e m ajority o patien ts w ith a com plex lon g-term
h istory o in ection with MRSA are treated with resection
arth roplasty as an en d poin t. Little data can predict a patien ts
appropriaten ess or u tu re reim plan tation , an d th is m u st be
com m u n icated in su ch cases.
As n oted above in th is case th e u ln ar stem w as loose an d
th e h u m eral stem w as w ell xed, so a posterior h u m eral
cortex osteotom y w as com pleted to h elp w ith exposu re o
th e proxim al portion o th e h u m eral stem or rem oval. Th is
cortical w in dow w as repaired w ith resorbable su tu re a ter
debridem en t. Cem en t rem oval, exten sive debridem en t, an d
c
419
 Se ct io n 3Case s
19.8
Implant
removalchronically
infe cte d
total
e lbow
arthroplasty

irrigation w ere com pleted, an d th e m edial con dyle an d sh a t 10 Pe a rls

w ere con tou red to en circle th e rem ain in g olecran on . Wou n d
closu re w as com pleted an d th e triceps in sertion w as m ain -
tain ed. A drain w as placed an d a splin t applied a ter dressin g
th e in cision .
Postoperatively, th e in ectiou s diseases specialist recom -
m en ded in traven ou s van com ycin th rou gh a periph erally
in serted cen tral cath eter lin e or 8 w eeks an d con tin u ed oral
su pplem en tation or 6 m on th s. In traoperative cu ltu res again
ou n d MRSA grow th th at w as su sceptible to van com ycin .
Th e patien t w as kept in a rem ovable elbow brace locked at
60 sh ort o u ll exten sion or 2 w eeks an d later tted w ith
a con tou red th erm oplast posterior lon g-arm splin t. Ph ysical
th erapy w as started or passive an d active-assisted ROM
a ter 2 w eeks. Weekly blood sam ples dem on strated im prove-
m en ts in th e CRP an d ESR levels, an d th e patien t clin ically
im proved w ith decreased elbow edem a an d an in cision th at
h ealed u n even t u lly. Elbow ROM im proved to an arc o 20
at u ll exten sion , to 120 o f exion .
9 Pit fa lls
Th e m ost com m on ly ch osen treatm en t option or
ch ron ic TEA in ection s is resection arth roplasty bu t i
th e patien t can n ot tolerate su rgery, lon g-term su ppres-
sive an tibiotics can be adm in istered in de n itely.
Th e u se o a sterile tou rn iqu et is appropriate bu t
exsan gu in ation w ith a com pressive Esm arch ban dage is
discou raged to avoid th e possibility o dissem in ation o
in ectiou s m aterial rom th e join t.
Meticu lou s so t-tissu e h an dlin g is em ph asized to avoid
devastatin g skin breakdow n or triceps in su cien cy.
Elevation o th ick m edial an d lateral f aps an d avoid-
an ce o skin pin ch in g w ith orceps is recom m en ded.
All attem pts sh ou ld be m ade to preserve bon e stock
an d th e in tegrity o th e h u m eral con dyles du rin g th e
cem en t extraction an d join t debridem en t.
Well- xed im plan ts pose a sign i can t tech n ical
ch allen ge in revision arth roplasty, an d osteotom ies o
th e h u m eru s or u ln a are occasion ally n ecessary.
Plan n in g th e len gth o a h u m eral or u ln ar osteotom y is
im portan t, so th at i reim plan tation is ch osen in u tu re,
a revision stem w ill bypass th e osteotom ized w in dow
by tw o cortical diam eters.
In cases w h ere in ection does n ot resolve postopera-
tively, a repeated irrigation an d debridem en t m ay be
per orm ed. I th e patien t can n ot m edically tolerate
addition al procedu res, lon g-term su ppressive an tibiotics
m ay be th e on ly rem ain in g option .
Resection arth roplasty m ay be th e best salvage treatm en t
in patien ts w h o h ave low u n ction al dem an ds or w h o
can n ot m edically u n dergo m u ltiple exten sive su rgeries.
A th orou gh su rgical debridem en t o th e so t tissu es
sh ou ld be com pleted, an d specim en s sh ou ld be sen t or
cu ltu res as w ell as rozen -section path ology.
Th e im plan ts, cem en t ragm en ts, an d pseu dom em -
bran es associated w ith th e im plan ts sh ou ld all be
rem oved w ith th e u se o osteotom es, cu rettes, ron -
geu rs, an d a h igh -speed bu rr. Creatin g a sm all w in dow
in th e posterior cortex o th e distal h u m eru s can
stream lin e th e rem oval process.
In traoperative im age in ten si cation can be u sed to
localize cem en t ragm en ts deeper in th e h u m eral an d
u ln ar can als th at n eed to be retrieved.
In resection arth roplasty requ irin g osteotom ies, su tu re
xation o osteotom y cortical w in dow s w ith resorbable
su tu res is pre erred over cerclage w ires or oth er
m etallic xation .
For resection arth roplasty, u ln oh u m eral stability is
m ain ly ach ieved by preservin g, i possible, th e m edial
an d lateral h u m eral con dyles w ith w h ich th e residu al
olecran on articu lates.
An an tibiotic-im pregn ated cem en t spacer or cem en t
beads can be placed.
A su ction drain sh ou ld be u sed, an d th e elbow is
im m obilized in exten sion .
Con su ltation w ith an in ectiou s diseases specialist is
h igh ly recom m en ded or an tibiotic m an agem en t an d
m on itorin g o in ection resolu tion .

420 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Anjan P Kaushik, John C Elfar
11 Ot h e r s u rgica l a lt e rn a t ive s a n d o u t co m e s
Variou s option s to treat an in ected TEA in clu de open or
arth roscopic irrigation an d debridem en t w ith reten tion o
com pon en ts, sin gle-stage im m ediate exch an ge arth roplasty,
tw o-stage revision arth roplasty, cem en ted arth rodesis, a
distal h u m eral or total h u m eral tu m or prosth esis, an d lon g-
term an tibiotic su ppression .
Debridem en t with reten tion o com pon en ts is gen erally on ly
reserved or cases w h ere th e sym ptom du ration is less th an
30 days, com pon en ts are w ell xed, th e patien t is in good
h ealth w ith a good so t-tissu e en velope, an d bacteriology on
aspiration reveals S aureus an d n ot Staphylococcus epidermidis
[4 , 2 5 ]. Open debridem en t typically in volves a posterior
approach , disarticu lation o th e com pon en ts, rem oval o th e
bu sh in gs, exten sive debridem en t, irrigation , an d addition o
an tibiotic-im pregn ated cem en t beads or pow der, in sertion
o n ew bu sh in gs, an d closu re. Th is procedu re h as a su ccess
rate o 70% eradication i S aureus is th e o en din g organ ism ,
bu t is associated w ith a h igh com plication rate [4]. Com plica-
tion s in clu de w ou n d breakdow n , triceps avu lsion or in su -
cien cy, an d periph eral n erve in ju ry [4, 29]. Arth roscopic
irrigation an d debridem en t w ith syn ovectom y h as also been
reported, with su ccess u l eradication o m eth icillin -sen sitive
S aureus in on e case [30], bu t th is is n ot a recom m en ded
treatm en t altern ative.
Sin gle-stage im m ediate revision arth roplasty, w h ich h as
been stu died m ore in th e low er extrem ity, is an option in
patien ts w h o h ave h ad a prior in ected elbow arth roplasty
or prior septic n ative elbow . In on e case series o S aureus
in ection s, ve o six elbow s th at u n derw en t im m ediate
exch an ge TEA h ad resolu tion o in ection , an d th e oth er
requ ired resection arth roplasty [3 1 ]. Th e in dication s or
sin gle-stage revision TEA are lim ited [2 5 , 3 2 ]; h ow ever, an d
in th e presen t case, prior sin gle-stage reim plan tation w as
n ot su ccess u l at eradicatin g in ection . It is probably tru e
th at special con sideration sh ou ld be given to th e con se-
qu en ces o ailu re to eradicate th e in ection in patien ts w h o
are can didates or sin gle-stage revision . Th is con sideration
sh ou ld n atu rally in clu de th e presen ce o arth roplasties in
oth er join ts th at are at risk or seedin g. I a sin gle-stage
revision h as a h igh er likelih ood o ailu re th an a tw o-stage
revision , th en tw o-stage revision sh ou ld be stron gly con -
sidered in su ch patien ts w h o h ave oth er join ts su sceptible
to seedin g.
Staged exch an ge arth roplasty h as been sh ow n in som e series
to be som ew h at su ccess u l or eradication o in ection an d
preservation o im plan t an d elbow u n ction [4, 9, 26 ]. In dica-
tion s or su rgical treatm en t in clu de avorable h ealth o th e
patien t to tolerate a revision procedu re, su cien t bon e stock
in th e h u m eru s an d u ln a or recon stru ction , eviden ce o
loose com pon en ts, an d sym ptom du ration o m ore th an 30
days [25]. Persisten t w ou n d drain age or w ou n d deh iscen ce
also w arran ts early operative in terven tion [13].
Du rin g secon d-stage revision elbow arth roplasty (reim plan -
tation ), th e sam e posterior in cision is u sed an d adh esion s
are released to expose th e u ln oh u m eral join t. Th e cem en t
spacer an d/ or beads are rem oved, an d at least th ree tissu e
an d f u id sam ples are again sen t to path ology or rozen -
section m icroscopic exam in ation to con rm th e absen ce o
organ ism s an d in f am m ation . I h istology reveals n o acu te
in f am m ation , th e su rgeon can proceed with preparin g th e
m edu llary can als o th e h u m eru s an d u ln a or th e n ew
im plan ts [9, 26]. Th e bon e su r aces are irrigated w ell an d dried
prior to in trodu cin g th e an tibiotic cem en t. A cem en t restrictor
m ay be u sed to lim it exten sion proxim ally in th e h u m eru s.
I h u m eral or u ln ar osteotom ies w ere per orm ed in th e rst
stage, th e cortical w in dow s are replaced an d stabilized w ith
cerclage cables a ter th e appropriately sized lon g-stem m ed
im plan ts are in serted. Allogra t stru ts can be u sed as an au g-
m en t option [9, 25]. Th e in cision is again care u lly closed over
a drain , an d a lon g-arm splin t in exten sion is m ain tain ed or
48 h ou rs to lim it h em atom a orm ation an d ten sion on th e
closu re. No u rth er an tibiotics are n eeded, an d patien ts are
allow ed to w ork w ith ph ysical an d occu pation al th erapy or
elbow ROM. Li etim e restriction s lim itin g li tin g to < 4.5 kg
an d repetitive li tin g < 1 kg are sim ilar to th ose a ter prim ary
TEA [9].
A u n iqu e salvage treatm en t option is th e u se o a tu m or
en doprosth esis su ch as a total h u m eral replacem en t or distal
h u m eral replacem en t. Th is m ay be u sed in patien ts w h o
h ave ailed m u ltiple elbow an d/ or sh ou lder revision arth ro-
plasties; h ow ever, th e literatu re [33] is lim ited to case reports,
an d th is m eth od h as n ot been exten sively stu died.
Cem en ted arth rodesis or periprosth etic in ection is an oth er
possible solu tion , h ow ever, th is h as been associated w ith
an u n acceptably h igh com plication rate an d revision rate
secon dary to rein ection , h ardw are ailu re, or brou s n on -
u n ion [34].
421
 Se ct io n 3Case s
19.8
Implant
removalchronically
infe cte d
total
e lbow
arthroplasty
12 Re fe re n ce s
1. Ba k s i DP, Pa l AK, Ba k s i D. Prosth etic
replacem en t o elbow or in tercon dylar
ractu res (recen t or u nu n ited) o
h u m eru s in th e elderly. Int Orthop. 2011
Au g;35(8):11711177.
2. Sch n e e b e rge r AG, Me ye r DC, Yia n EH.
Coon rad-Morrey total elbow
replacem en t or prim ary an d revision
su rgery: a 2- to 7.5-year ollow-u p
stu dy. J Shoulder Elbow Surg. 2007
May-Ju n ;16(3 Su ppl):S4754.
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arth roplasty or th e treatm en t o
rh eu m atoid arth ritis o th e elbow.
J Bone Joint Surg Am. 1992
Apr;74(4):479 490.
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In ection a ter total elbow arth roplasty.
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arth roplasty. J Am Acad Orthop Surg.
2011 Ju n ;19(6):328 339.
6. Kre n e k L, Fa rn g E, Zin gm o n d D, e t a l.
Com plication an d revision rates
ollow in g total elbow arth roplasty.
J Hand Surg Am. 2011 Jan ;36(1):68 73.
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arth roplasty. An 18-year experien ce.
Clin Orthop Relat Res. 1993
May;(290):177188.
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Com plication s o total elbow
replacem en t: a system atic review.
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Jan ;20(1):158 168.
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Reim plan tation o a total elbow
prosth esis ollow in g resection
arth roplasty or in ection . J Bone Joint
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e t a l. Treatm en t strategies or
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elbow arth roplasty. J Shoulder Elbow
Surg. 2012 Au g;21(8):992 10 00.
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e t a l. Postoperative resu lts an d
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arth roplasty in patien ts w ith
rh eu m atoid arth ritis: th ree types o
n on con strain ed arth roplasty. Modern
Rheumatol. 2008 Oct;18(5):465 471.
12. Ho w e CR, Ga rd n e r GC, Ka d e l NJ.
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or th e patien t w ith rh eu m atoid
arth ritis. J Am Acad Orthop Surg. 2006
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13. Je o n IH, Mo rre y BF, An a k w e n ze OA,
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com plication s a ter total elbow
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15. Ma n s a t P, No u a ille De go rce H,
Bo n n e via lle N, e t a l. Total elbow
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ractu res in patien ts over 65 years old
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2013 Nov;99(7):779 78 4.
16. Ch a lid is B, Dim it rio u C, Pa p a d o p o u lo s
P, e t a l. Total elbow arth roplasty or th e
treatm en t o in su cien t d istal h u m eral
ractu res. A retrospective clin ical stu dy
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17. Th ro ckm o r t o n T, Za rka d a s P, Sa n ch e z-
So t e lo J, e t a l. Failu re pattern s a ter
lin ked sem icon strain ed total elbow
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18. Pra s a d N, De n t C. Ou tcom e o total
elbow replacem en t or distal h u m eral
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ailed in tern al xation or con ser vative
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Mar;90(3):343 348.
19. De m ira lp B, Ko m u rcu M, Ozt u rk C, e t a l.
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gu n sh ot in ju ries: 8- to 12-year
ollow-u p stu dy. Arch Orthop Trauma
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e t a l. Ou tcom es in total elbow
arth roplasty in patien ts w ith
h aem oph ilia at th e Un iversity o
Cali orn ia, San Fran cisco: a
retrospective review. Haemophilia. 2011
Jan ;17(1):118 123.
21. Ce lli A, Mo rre y BF. Total elbow
arth roplasty in patien ts orty years o
age or less. J Bone Joint Surg Am. 2009
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22. Ba gh d a d i YM, Ve ille t t e CJ, Ma lo n e AA,
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May 7;96(9):e70.
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e t a l. Ch aracteristics an d ou tcom e o 27
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Man agem en t o th e in ected total join t
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e t a l. Two-stage revision or th e
treatm en t o th e in ected total elbow
arth roplasty. Bone Joint J. 2013
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e t a l. Th e valu e o in traoperative
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Sem icon strain ed total elbow
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e t a l. Upper extrem ity recon stru ction
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Arth rodesis or ailed total elbow
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Mar;23(3):302307.
Ste phe n L Kate s, Olivie r Bore ns
The ddy Slongo
20 Pe d ia tric o s te o m ye litis
Th e d d y Slo n go
1 In t ro d u ct io n
In con trast to adu lts, w h o gen erally develop osteom yelitis
du e to an open bon e in ju ry or as a com plication a ter a
su rgical procedu re (osteosyn th esis, join t replacem en t), pe-
diatric osteom yelitis is u su ally acqu ired via a h em atogen ou s
rou te [1, 2], o ten w ith ou t an obviou s cau se. Th ere ore, th e
diagn osis is o ten m ade late a ter oth er cau ses o ever or
illn ess are con sidered. Especially in you n g ch ildren , a delayed
diagn osis an d late in itiation o th erapy o ten leads to severe
an d perm an en t dam age [3].
Th e age o th e ch ild is cru cial. In you n ger ch ildren , osteo-
m yelitis is o ten cou pled w ith pu ru len t arth ritis leadin g to
join t destru ction i th e diagn osis is m issed or delayed [4].
Early diagn osis an d an early start to th erapy are th ere ore
param ou n t. As a ru le w e can say th at th e you n ger th e ch ild
th e m ore im portan t it is to treat early to preven t lon g-term
sequ elae.
1.1 Occu rre n ce a n d s o cio e co n o m ic b a ck gro u n d o f
o s t e o m ye lit is
Ch ildren get osteom yelitis in th e 21st cen tu ry depen din g
on th eir socioecon om ic backgrou n d. Wh ile th e h em atoge-
n ou s osteom yelitis occu rs in developed cou n tries, in less
developed cou n tries or region s w ith poor m edical care,
local osteom yelitis cau sed by open w ou n ds or ractu res an d
poor h ygien ic care, an d lack o an tibiotics is m ore com m on ly
seen [57].
1.2 Age o f o n s e t
Alm ost 80% o all cases o h em atogen ou s osteom yelitis
occu r in ch ildh ood, w ith 8090% occu rrin g in th e rst 2
years o li e. Th e path oph ysiology sh ow n below explain s
w h y in th is age grou p osteom yelitis is alm ost alw ays ac-
com pan ied by septic arth ritis. Osteom yelitis in ch ildh ood is
a m etaph ysitis w h ich u su ally in volves th e join t.
A ter pu berty, with th e closu re o th e growth plate, pediatric
osteom yelitis dem on strates an iden tical path ology pattern
to th at seen in adu lts [8].
423
 Se ct io n 3Case s
20Pe diatric
oste omyelitis

1.3 Mo rp h o lo g y a n d a n a t o m y
Th e em ergen ce o h em atogen ou s osteom yelitis an d osteo-
arth ritis accordin g to age is directly related to th e m orph o-
logical stru ctu re o th e epiph ysis an d m etaph ysis in ch ildren
( Fig 20 -1 ).

With septic in f am m ation com es an in crease in pressu re in

th e m etaph yseal an d diaph yseal area o th e bon e w ith re-
du ction o blood su pply, w h ich in ter eres w ith th e im m u n e
system respon se to th e in ection . System ic an tibiotics also
h ave redu ced access to th e site o in ection [4].

Articular cartilage
Epiphysis
Epiphyseal artery

Epiphyseal line

Metaphysis
Metaphyseal artery

Periosteum

Periosteal arteries

Medullary cavity

Diaphysis Compact bone

Nutrient foramen

Nutrient artery

a b
Fig 20 -1a b Vascularity of the e pim e taphyse al re gion in the proxim al tibia.
a Histological cross-se ction through the e pim e taphyse al re gion with no ve sse ls passing the growth plate .
b Cross-se ction with diffe re nt ve sse ls; note that all ve sse ls for the e piphysis are not com ing from the m e taphysis.

424 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo

1.4 Tim in g a n d p a t h o p h ys io lo g y
Tim e is on e o th e m ost im portan t determ in an ts or th e
ou tcom e o osteom yelitis an d septic arth ritis. Th e you n ger
th e ch ild, th e less tim e m ay elapse be ore treatm en t. Th e
critical tim e lim it sh ou ld n ot exceed 2448 h ou rs. System ic
an tibiotics m ay lim it th e in f am m atory process, bu t w ill n ot
im prove th e ou tcom e. Ta b le 20-1 sh ow s th is relation sh ip as
a u n ction o th e type o in f am m ation an d age [8].
Th e path oph ysiology di ers betw een osteom yelitis an d
septic arth ritis. Aw aren ess o th ese di eren ces is im portan t
or an early diagn osis an d an im portan t actor or th e ou tcom e.
Ta b le 20 -2 gives a h elp u l overview o th e path oph ysiological
di eren ces.

Days Change Method

MRI BS S X-ray
03 Pain + +
Inflammation/hyperemia
35 Soft-tissue swelling + + +
Marrow edema/thrombosis -
7(10)14 Osteoporosis/osteolysis + + +
Coalescence/bone perforation +
1014 Reaction of the periosteum +
Reparation
Sclerosis +

Ta b le 20-1 The signi cance of clinical and paraclinical signs from

the rst symptom s to chronic infe ction.
Abbre viations: MRI, magne tic re sonance imaging; BS, bone scan;
S, sonography.

Os te o m ye litis Purule nt arthritis

Hematogenic infection of the medullary zone particularly the metaphyseal segment
Inflammatory increase of interosseous pressure within the first 2448 hours
Capillary leak, limitation of the blood circulation within the following 37 days; hyperemia
of the periphery
Breakthrough of the infection through the cortex to the subperiosteal space and to the
epiphysis
Destroying bone matrix followed by osteolysis
Involvement of the soft tissue and perforation (fistula) through the skin
Additional hematogenic seed with new infection is possible
Hematogenic or direct osteogenic infection of the synovia
Hyperemia/enrichment of the synovia with granulocytes, these secrete proteolytic
enzymes (collagenase)
Destruction of joint cartilage within 26 days
Effusion formation with increasing intraarticular pressure leads to circulatory disorder and
necrosis
Destruction of the capsule joint dislocation
Formation of fibrin also leads to malnutrition of the cartilage
Destruction of the cartilage leads to ankyloses of the joint
Along-lasting hyperemia in the hip leads to coxa magna

Ta b le 20-2 The pathoge nic and pathophysiological ste ps during a bone or joint infe ction in childhood.

425
 Se ct io n 3Case s
20Pe diatric
oste omyelitis

1.5 Et io lo g y 1.6 Lo ca t io n o f p e d ia t ric in fe ct io n s

A su m m ary o th e m edical literatu re an d person al experien ce sh ows th e requ en cy o body sites o osteom yelitis
Ta b le 20-3
is described or th e developm en t o acu te osteom yelitis: an d septic arth ritis. It su m m arizes th e au th ors ow n clin ical
data an d literatu re su rvey.
Acu te osteom yelitis u su ally occu rs in ch ildren .
It is u su ally a h em atogen ou s in ection rom rem ote For an early diagn osis o septic arth ritis an d osteom yelitis
ocu s. it is im portan t to com bin e di eren t aspects, su ch as patien t
Th e m ost com m on organ ism s respon sible in clu de: h istory, clin ical n din gs, an d visu al n din gs. Th e an alysis
Staphylococcus aureus an d syn th esis o th is com bin ation o actors determ in es
Streptococcus pyogenes early treatm en t. In addition , th e su bsequ en t diagn ostic
Hemophilus inf uenzae w orku p resu lts give u s th e de n itive diagn osis ( Ta b le 20 -4 ).
Gram -n egative organ ism s
Salmonella in ection s are o ten seen in ch ildren w ith
sickle-cell an em ia.
Th e site o in ection is u su ally th e m etaph ysis o lon g
bon es. Osteomyelitis %
Femur 26
Tibia 25
Humerus 12
Fibula/radius/phalanges/calcaneus 5

Septic arthritis
Knee joint 40
Hip joint 23
Elbow joint 14
Ankle joint 13

Ta b le 20-3 Fre que ncy of oste om ye litis and se ptic arthritis in spe ci c
body site s.

Pa tie nt his to ry Clinica l f ndings Labo ra to ry te s ts

Relieving posture Local tenderness WBC/ESR/CRP
Fever Fever Rheumatoid factor/titer
Malaise, fatigue Swelling/warmth Positive blood cultures
Pain Poor function/pseudoparalysis Kidney function BUN/creatinine
Previous infection
Vis ua l dia g no s tics Surg ica l
Plain x-ray in two planes Even if limited suspicion of infectious arthritis, always
Sonography aspirate the joint with patient under anesthesia,
Bone scan (if localization is unclear) independently of the duration of symptoms
MRI postprimary if situation is unclear Gram stain, culture and sensitivity, cell count, and
CTscan (2-D reconstruction) differential
If results are positive (purulent fluid) proceed to
arthrotomy and drainage
If subperiosteal liquid is present, surgical approach
recommended if history longer than 48 hours

Ta b le 20-4 Sum m ary of diffe re nt diagnostics and the ir im plications for furthe r tre atm e nt.
Abbre viations: MRI, m agne tic re sonance im aging; WBC, white blood ce ll; ESR, e rythrocyte se dim e ntation rate; CRP, C-re active prote in; BUN,
blood, ure a, nitroge n; MRI, magne tic re sonance im aging; CT, com pute d tom ographic.

426 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo

To avoid u n n ecessary an tibiotic th erapy or su rgery it is 1.7 Th e ra p e u t ic a lgo rit h m

im portan t to u n derstan d th e di eren ces in diagn ostic
w orku p betw een a septic an d a reactive arth ritis as sh ow n
in Ta b le 20 -5 .
Th e ollowin g au th ors clin ical list (in patien t care) ( Ta b le 20-6 )
o ers a sa e algorith m or adequ ate treatm en t; th is treatm en t
m u st be adapted to th e bacteriological resu lts (resistan ce) as
soon as possible. Th is treatm en t algorith m is adapted rom
th e treatm en t m odalities o Nade [9].

Examination Normal Nonin ectious e usion Septic e usion

Quantity of effusion < 3.5 mL Often > 3.5 mL Often > 3.5 mL
Transparency Transparent Transparent Cloudy
Color Clear Yellowish Yellow-greenish
Viscosity High High Different, often low
White blood cells, cells/L < 200 2002,000 > 100,000
Polymorphic leukocytes < 25% < 25% > 75%
Bacteriology Negative Negative Frequently positive
Glucose, mmol/L Similar to serum Similar to serum 50% of serum value

Ta b le 20-5 The laboratory e xamination re sults of joint uid com paring se ptic and re active arthritis in childhood.

Intravenous antibiotics Joints Osteomyelitis

According to the most frequent pathogens: If suspicious Even if sonography shows no subperiosteal liquid to be
Staphylococcus aureus Always aspirate and/or lavage visible, but bone scan is positive, start with antibiotics
Streptococcus Particularly for hip joint Regularly repeat sonography
Gram-negative bacteria Effusions > 8 mm must always be aspirated Consider obtaining MRI scan of body site
Adaptation of the antibiotics upon receipt of possible Plain x-rays should be obtained after 1012 days; at this
resistances time radiological changes become visible
Immobilization If there is appearance of fluid collection or bony lesions are
Hip joint noted, surgery is indicated to drain the fluid and debride
Skin traction the site
Other joints
Plaster-cast splints
Suspicion of osteomyelitis
Plaster-cast splint of the corresponding extremity

Ta b le 20-6 Algorithm for safe tre atm e nt, to be adapte d to bacte riological re sults.
Abbre viation: MRI, m agne tic re sonance im aging.

427
 Se ct io n 3Case s
20Pe diatric
oste omyelitis
1.8 Pro gn o s is o f p e d ia t ric in fe ct io n s
A good progn osis i th ere is:
Early diagn osis (patien t h istory n ot lon ger th an 48
h ou rs prior to th e start o th erapy)
Path ogen -speci c an tibiotics u sed rath er th an em piric
treatm en t
Rapid clin ical im provem en t n oted (im provem en t o th e
sym ptom s w ith in 2448 h ou rs)
No visible radiological or son ograph ic n din gs
A bad progn osis i th ere is:
A tim e in terval betw een sym ptom s to start o th erapy
> 5 days
Persisten ce o sym ptom s
An appearan ce o su blu xation or dislocation on plain
x-rays
An appearan ce o join t or bon e abn orm ality on plain
x-rays
In adequ ate an tibiotic th erapy
Too sh ort a cou rse o an tibiotic th erapy (46 w eeks
orally)
Th e best progn osis occu rs i th ere is:
A tim e in terval betw een diagn osis to th erapy < 3 days
Radiological bon e alteration s or lesion s visible early
an d con sequ en tly a com bin ed approach to treatm en t
Com bin ed an tibiotic th erapy an d su rgery
428
2 Su m m a r y
Un treated or late recogn ition or diagn osis o osteom y-
elitis an d septic arth ritis h as seriou s im plication s or
th e ch ild.
Early diagn osis is essen tial, in clu din g aspiration o a
join t or f u id collection .
Th e an tibiotic th erapy m u st be started im m ediately.
I th e sym ptom s do n ot disappear w ith in 48 h ou rs or
bon y lesion s or articu lar ch an ges are n oted, su rgical
in terven tion sh ou ld be u n dertaken im m ediately.
Failu re to recogn ize th e n eed or a ch an ge in th erapy
can h ave devastatin g con sequ en ces or th e ch ild.
3 Re fe re n ce s
1. Ca rm o d y O, Ca w e ly D, Do d d s M, e t a l. Acu te h aem atogen ou s
osteom yelitis in ch ildren . Ir Med J. 2014 Oct;107(9):269 270.
2. St re e t M, Pu n a R, Hu a n g M, e t a l. Ped iatric acu te h em atogen ou s
osteom yelitis. J Pediatr Orthop. 2015 Sep;35(6)634 639.
3. Fa d e n H, Gro s s i M. Acu te osteom yelitis in ch ildren .
Reassessm en t o etiologic agen ts an d th eir clin ical
ch aracteristics. Am J Dis Child. 1991 Jan ;145(1):65 69.
4. Ya gu p s k y P, Ba r-Ziv Y, Ho w a rd CB, e t a l. Epidem iology, etiology,
an d clin ical eatu res o septic arth ritis in ch ildren you n ger th an
24 m on th s. Arch Pediatr Adolesc Med. 1995 May;149(5):53754 0.
5. Ch ris t ia n s e n P, Fre d e rik s e n B, Gla zo w s k i J, e t a l. Epidem iologic,
bacteriologic, an d lon g-term ollow-u p data o ch ildren w ith
acu te h em atogen ou s osteom yelitis an d septic arth ritis: a
ten -year review. J Pediatr Orthop B. 1999 Oct;8(4):302305.
6. Bick le r SW, Ro d e H. Su rgical services or ch ild ren in developin g
cou n tr ies. Bull World Health Organ. 2002;80(10):829 835.
7. La u s ch ke FH, Fre y CT. Hem atogen ou s osteom yelitis in in an ts
an d ch ild ren in th e n orth western region o Nam ibia.
Man agem en t an d two-year resu lts. J Bone Joint Surg Am. 1994
Apr;76(4):502510.
8. Bo n h o e ffe r J, Ha e b e rle B, Sch a a d UB, e t a l. Diagn osis o acu te
h aem atogen ou s osteom yelitis an d septic arth ritis: 20 years
experien ce at th e Un iversity Ch ildren s Hospital Basel. Swiss
Med W kly. 2001 Oct 6;131(39-40):575 581.
9. Na d e S. Ch oice o an tibiotics in m an agem en t o acu te
osteom yelitis an d acu te septic arth ritis in ch ildren . Arch Dis
Child. 1977 Sept;52(9):679 682.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
The ddy Slongo

20 .1 Os te o m ye litis o f th e d is t a l tib ia
Th e dd y Slon go

1 Ca s e d e s crip t io n 1.1 Clin ica l e xa m in a t io n

A 3-year-old boy presen ts w ith a 5-day h istory o in creasin g
pain in th e le t low er leg. A ter 2 days o ever (38.5 C),
h is m oth er n otices sw ellin g in th e le t distal low er leg. Th e
ch ild is n ot able to w alk on th e a ected extrem ity.
Th e am ily ph ysician s prim ary diagn osis w as ph aryn gitis
an d probably a trau m a o th e low er leg. Blood exam in ation
sh ow s a m ild leu kocytosis. Th erapy w as to m edicate th e
ever an d bed rest.
3-year-old boy w ith w eaken ed con dition , ever 39.5 C
Un able to w alk
Local le t low er leg exam in ation dem on strated sw ellin g,
w arm th , redn ess, an d ten dern ess in th e distal th ird o
th e leg
In gu in al lym ph n odes sw ollen an d pain u l

Tw o days later, an in creasin g ever (u p to 40 C) developed

w ith in creasin g pain an d sw ellin g o th e le t low er leg. Th e
ch ild w as taken back to th e am ily ph ysician w h o adm in is-
tered an tibiotics (am oxicillin / clavu lan ic acid). Advice to th e
m oth er w as to call again th e ollow in g day i h e w as n ot
better. Th ere w as n o im provem en t th e n ext day, so th e ch ild
w as sen t to th e ch ildren s h ospital.

429
 Se ct io n 3Case s
20 .1Oste omye litis
of
the
distal
tibia

1.2 Ad d it io n a l e xa m in a t io n Becau se o th e obviou s localized sym ptom s, th e n ext ex-

Laboratory w orku p:
Wh ite blood cell cou n t > 30,000 cells/ L
Eryth rocyte sedim en tation rate > 40 m m / h
C-reactive protein > 300 m g/ L
X-ray: low er leg AP an d lateral; n orm al lateral view o th e
bon e; som e sw ellin g o th e so t tissu e is n oted ( Fig 20 .1-1 ).
am in ation or th is age grou p is son ograph y ( Fig 20 .1-2 ,
Fig 20 .1-3 ).
Both th e distal tibia an d th e join t are exam in ed w ith u ltra-
sou n d. A clin ical pictu re o th e exam in ation tech n iqu e is
sh ow n in Fig 20 .1-3 a .

a b
Fig 20 .1-1a b X-rays of the lowe r le g.
a AP vie w. Me dial arrow 1 shows an e ffusion of the
ankle joint.
b Late ral vie w. Arrow 2 shows the poste rior swe lling
be twe e n the fascial laye rs. Arrow 3 shows the pus
pe ne trating the fascia cre ating a subcutane ous
absce ss. b
Fig 20 .1-3 a b Ultrasound e xam ination of the distal tibia.
a Photograph of ultrasound e xamination te chnique .
b Ultrasound im age showing the absce ss ove r the corte x
surface (arrows).

Fig 20 .1-2 Sonographic im age . Arrow 1 shows the ankle

joint e ffusion; arrow 2 , the fascial laye r swe lling; and arrow
3, the pus pe ne trating the fascia cre ating a subcutane ous
absce ss.

430 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo

2 In d ica t io n 4 Pa t ie n t p o s it io n in g

Th e clin ical an d patien t h istory an d resu lts o th e blood Th e ch ild is position ed su pin e. Th e leg is draped sterilely
exam in ation an d son ograph y are clear in dication s or su rgi- over th e kn ee join t so th at th e kn ee can be ben t an d th e
cal in terven tion . Delay w ill in crease th e risk or a system ic low er leg m oved reely ( Fig 20 .1-4 ).
sepsis an d addition al dam age o th e distal tibial ph ysis.
Th e au th or pre ers to h ave th e kn ee ben t an d position ed on
a m obile, sterile leg h older ( Fig 20.1-5 ).
3 Pre o p e ra t ive p la n n in g
A n on sterile tou rn iqu et is u sed on th e th igh (300 m m Hg).
Son ograph ic localization o th e process w as con cordan t w ith
x-ray n din gs an d h elped w ith plan n in g o an an terolateral
approach ; i n eeded, rom th e sam e in cision , th e posterior
tibia can also be explored. In Fig 20 .1-1 th e m edial arrow 1
sh ow s an e u sion o th e an kle join t. On th e lateral view
arrow 2 sh ow s th e posterior sw ellin g betw een th e ascial
layers.

Fig 20 .1-4 The child is positione d supine . The le g is drape d ste rile ly
ove r the kne e joint so that the kne e can be be nt and the lowe r le g
m ove d fre e ly.

Fig 20 .1-5 The kne e is be nt and positione d on a m obile , ste rile le g

holde r.

431
 Se ct io n 3Case s
20 .1Oste omye litis
of
the
distal
tibia

5 Su rgica l a p p ro a ch 7 Te m p o ra r y fixa t io n

A 1215 cm lon g skin in cision is per orm ed as sh ow n in
Fig 20 .1-6 . A ter th e in cision o th e ascia, exposu re o th e
ten don s an d m u scles is ach ieved by blu n t dissection .
As w as eviden t on th e son ograph y, th e pu s h as per orated
th e periosteu m an d th e deep ascia so th e pu s drain ed u n der
pressu re.
6 Su rgica l d e b rid e m e n t
For pain m an agem en t an d care, it is recom m en ded to apply
a dorsal low er leg plaster cast, or better, a berglass cast split
or a pre abricated splin t. Th e au th or pre ers a precon tou red
U-cork splin t ( Fig 20.1-8 ) w h ich is easy to ch an ge or w ou n d
con trol an d n u rsin g, an d is also w ash able.
In m ore critical cases an d in older ch ildren , application o
a sm all extern al xator or im m obilization an d elevation o
th e leg is recom m en ded.

A ter irrigation o th e di eren t areas arou n d th e m u scles

an d su bperiosteal space, th e an kle join t m u st also be open ed.

Th e capsu le is open ed, irrigated, an d drain ed.

Becau se th e origin o th e in ection is in th e bon e, th e cortex

m u st be open ed w idely by ch isel or bu rr ( Fig 20 .1-7 ).

Th e bon e is drain ed or 34 days.

Fig 20 .1-7 The origin of the infe ction is in the bone so the corte x
m ust be ope ne d wide ly by chise l or burr.

Fig 20 .1-6 A 1215 cm long skin incision is made . Fig 20 .1-8 A pre contoure d U-cork splint.

432 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo
8 Po s t o p e ra t ive m a n a ge m e n t
Th e ch ild sh ou ld receive in traven ou s an tibiotics or at least
714 days depen din g on th e blood test resu lts; it is recom -
m en ded to in itiate a lon ger-term in traven ou s approach . Th e
au th or recom m en ds a cen tral ven ou s cath eter. Th is is m ore
com ortable or th e ch ild an d preven ts m u ltiple n ew pain u l
ven opu n ctu res.
Th e drain s rem ain in place or at least 23 days.
A ter w ou n d h ealin g, a low er leg so t cast is applied or at
least 46 w eeks u n til th ere is eviden ce o good bon e con -
solidation o th e bon e w in dow .
Lon g-term oral an tibiotics are con tin u ed u n til th e C-reactive
protein level h as n orm alized, typically at least 46 w eeks.
9 Ou t co m e
In th is case th e h ealin g occu rred w ith ou t com plication as
expected. In th e lon g-term ollow -u p n o axial deviation an d
n o grow th arrest w as seen . Fu n ction o th e an kle join t
retu rn ed to n orm al a ter 8 w eeks.
10 Pit fa lls
Regardin g th e ch ilds age, th e sym ptom s, an d th e local
situ ation , th e diagn osis sh ou ld n ot h ave been m issed or th e
sym ptom s sh ou ld n ot h ave been m isin terpreted or su ch a
lon g tim e. In th is case th e algorith m sh ow n in Ta b le 20 -3
w ou ld lead to th e correct diagn osis earlier, perm ittin g m ore
tim ely treatm en t.
11 Pe a rls
Th e correct in terpretation o sym ptom s leads to early diag-
n osis an d treatm en t w ith in traven ou s an tibiotics. In m ost
cases an tibiotic th erapy w ith in th e rst 24 h ou rs can preven t
su rgery. A h igh in dex o su spicion or th e diagn osis o in ec-
tion is essen tial.
433
 Se ct io n 3Case s
20 .1Oste omye litis
of
the
distal
tibia

434 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo
20 .2 Os te o m ye litis o f th e p ro xim a l h u m e ru s
The dd y Slon go
1 Ca s e d e s crip t io n
A 14-year-old boy presen ted w ith recu rren t ever or 3 w eeks
an d in creasin g pain in th e le t sh ou lder. Th e boy h ad a
h istory o allin g on to th e le t sh ou lder du rin g gym n astics.
Th e irst con su ltation w ith h is gen eral practition er w as
approxim ately 10 days a ter th e on set o sym ptom s.
Th e diagn osis o th is con su ltation w as pain u l sw ellin g o
th e le t sh ou lder an d proxim al h u m eru s com patible w ith
trau m a. X-rays sh ow ed n o ractu re ( Fig 20.2-1 ). Th e recom -
m en dation o th e gen eral practition er w as pain m edication ,
arm slin g, an d to retu rn or assessm en t i th e sym ptom s did
n ot resolve a ter a ew days.
1
2
a b
In a secon d con su ltation 5 days later th e boy h ad th e sam e
sym ptom s, in creasin g pain , an d m ore sw ellin g. He h ad
n orm al body tem peratu re. Blood tests sh ow ed C-reactive
protein (CRP) level betw een 8090 m g/ L an d w h ite blood
cell cou n t o 12,000 cells/ L. Th erapy at th is tim e w as u se
o a slin g, to con tin u e with pain m edication , an d prescription
steroids.
On th e ollow -u p exam in ation th e patien t h ad in creasin g
sw ellin g an d pain . Th e gen eral practition er sen t th e boy to
th e local h ospital or u rth er in vestigation .
New blood tests sh ow ed CRP level > 250 m g/ L an d w h ite
blood cell cou n t > 20,000 cells/ L.
Fig 20.2-1 a b Initial x-rays m ade by the ge ne ral practitione r
3 we e ks be fore admission to the author's hospital. The se x-rays we re
com ple te ly m isinte rpre te d as norm al. On the AP ( a ) and late ral ( b )
vie ws we se e the following pathological signs:
1 Im portant swe lling of the re gion of the de ltoid muscle .
2 Pathological change s of the m e taphyse al proxim al part of the
hum e rus with scle rotic and oste olytic zone s.
The se signs are highly suspicious for an active proce ss in the bone
and soft-tissue infe ction or an aggre ssive tum or.
435
 Se ct io n 3Case s
20 .2 Oste omye litis
of
the
proximal
humerus

Son ograph y w as obtain ed sh ow in g a su bcu tan eou s cystic
m ass 14.7 cm lon g an d 3.8 cm th ick ( Fig 20 .2 -2 ). In addition ,
a com pu ted tom ograph ic (CT) scan w as per orm ed ( Fig 20 .2-
3a c ).
For th e treatin g pediatrician an d th e radiologist th e situ ation
w as u n clear an d th ey decided to per orm a n eedle aspiration
o th e cystic lesion w h ich yielded a lot o pu s.
Diagn osis at tran s er w as su bcu tan eou s abscess. Th e ch ild
w as tran s erred w ith th is diagn osis to th e au th ors clin ic.
1.1 Clin ica l e xa m in a t io n
At adm ission to th e au th ors clin ic em ergen cy departm en t
th e boy presen ts w ith th ese sym ptom s:
Hyperem ic sh ou lder an d h u m eral region
Dou gh y sw ellin g
Pain u l an d pseu doparalytic sh ou lder
1.2 Ad d it io n a l e xa m in a t io n
In th is case n o addition al exam in ation s w ere carried ou t.
Th e prior son ograph y pictu res, CT scan w ith 2-D recon stru c-
tion , an d blood tests w ere obtain ed.

Dist = 14 .7 cm Dist = 3.8 cm

a b
Fig 20.2-2a b The ultrasound im age s show a large absce ss in the proxim al hum e rus 14 .7 cm
long and 3 .8 cm thick. The de fe ct in the cortical bone is also shown. This is a sign that the
infe ction or proce ss com e s from the bone .

436 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo

2 In d ica t io n 3 Pre o p e ra t ive p la n n in g

Accordin g to th e h istory, blood exam in ation valu es, an d
radiological in vestigation , th e diagn osis o an advan ced os-
teom yelitis w ith bon e stu la w as establish ed ( Fig 20.2 -3 d f ).
Sin ce th ere w as n o dou bt abou t th e active osteom yelitis,
in traven ou s an tibiotics w ere started (ie, clin dam ycin ). Even
th ou gh th e boy w as 14-years-old at th e tim e o adm ission ,
th e proxim al ph ysis w as still open . Th e paren ts w ere in -
orm ed abou t poten tial com plication s o grow th arrest or
m alalign m en t.

a b c

d e f
Fig 20 .2 -3 a f 3 -D CT scans ( a c ) and 2-D (d f ) x-rays.
a c In the 3 -D re constructions of the se com pute d tom ographic scans only the pe rforation on
the ante rom e dial side is shown. The se image s de m onstrate that 3 -D re constructions are
le ss he lpful for diagnosis than the m ore inform ative 2-D x-rays.
d f 2-D x-rays cle arly show the large lytic zone in the m e taphysis and the pe rforation of the
corte x which is re sponsible for the absce ss in the proxim al hum e rus. Howe ve r, the physis
is still not involve d.

437
 Se ct io n 3Case s
20 .2 Oste omye litis
of
the
proximal
humerus

4 Su rgica l a p p ro a ch Th e in cision w as m ade at th e an terior su lcu s alon g th e

Becau se th e abscess exten ded in a circu lar ash ion th rou gh
th e in term u scu lar an d su bcu tan eou s tissu es, it was im portan t
to discu ss w h ich approach w as th e least trau m atic an d best
or cu rettage o th e proxim al h u m eru s.
an terior border o th e deltoid m u scleth e deltopectoral
approach ( Fig 20.2-4 ), m akin g a blu n t dissection o th e m u scle
( Fig 20 .2 -5 ). Th e exposu re w as easy becau se o th e large
in term u scu lar abscess, so th e dissection w as m ostly accom -
plish ed by th e process.

Subscapularis tendon
Greater tuberosity Lesser tuberosity

Tendon of the long

head of the biceps

Axillary nerve

Fig 20 .2 -4 The approach to the proxim al-m e dial hum e rus was
m ade by a de ltope ctoral approach, along the ante rior borde r of the
de ltoid m uscle .

Musculocutaneous nerve Cephalic vein

Deltoid muscle
Ascending branch of the
anterior circumflex humeral artery Cephalic vein
Axillary nerve Clavipectoral fascia
Posterior circumflex
humeral artery

Anterior circumflex
humeral artery

Ulnar nerve

Brachial artery and vein

Median nerve
a b
Fig 20 .2 -5 a b Ne rve and vascular dam age can be pre ve nte d with the pre paration along the ante rior borde r of the de ltoid m uscle;
care ful atte ntion m ust be paid to the ce phalic ve in so rounde d sm ooth re tractors are re comm e nde d. In this case the disse ction was
ne arly com ple te ly pe rform e d by the absce ss.

438 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo

5 Su rgica l d e b rid e m e n t Th en , th e in ected an d destroyed can cellou s m etaph yseal

On ce all th e m u scles w ere dissected at least 2/ 3 o th e
circu m eren ce o th e proxim al h u m eru s w as exposed w ell.
Th e bon y stu la at th e an terior aspect o th e h u m eru s w as
visible.
Be ore open in g th e cortex o th e proxim al h u m eru s an d
per orm in g cu rettage, th e di eren t abscesses betw een th e
m u scles w ere debrided an d w ash ed ou t.
bon e w as rem oved leavin g a big h ole in th e proxim al m e-
taph ysis.
Th e stu la w as also debrided u sin g a cu rette.
As th e pu s w as m ostly located in th e so t tissu e an d in ter-
m u scu lar area an d less in th e m etaph ysis, n o drain w as
placed in th e bon e cavity. A gen tam icin -im pregn ated spon ge
w as placed in th e large m etaph yseal h ole. Th e w ou n d w as
th en closed w ith a ew deep stich es.

Tw o drain s w ere in serted, on e m ore proxim ally an d poste-

rior, th e oth er m ore distally an d an terior. 6 Te m p o ra r y fixa t io n

Th e bon e w as th en open ed u sin g a lon g cortical w in dow
m ore rom th e m edial side (as sh ow n on th e postoperative
x-rays) ( Fig 20 .2 -6 ). Th e reason or th at approach w as th e
th in cortex on th e m edial side w h ich cou ld easily be per o-
rated by n ger pressu re.
In th is case, th e bon e w as still stable w ith a m edial cortical
de ect so n o xation w as n eeded. It w as believed th at th e
w eakn ess created by presen ce o th e m edial de ect w as u n -
likely to ractu re.

a b
Fig 20 .2 -6 a b The postope rative x-rays show the m e dial de fe ct whe re the large window
was m ade . In this re gion the corte x was thin. In addition, we can se e the bigge r hole of the
stula afte r cure ttage .
a AP vie w.
b Late ral vie w.

439
 Se ct io n 3Case s
20 .2 Oste omye litis
of
the
proximal
humerus

7 Po s t o p e ra t ive m a n a ge m e n t 8 Ou t co m e

Wh ile th e su bcu tan eou s drain w as in place or 3 days th e
arm w as im m obilized in th e bed w ith in a slin g ( Fig 20.2 -7 ).
Accordin g to th e bacteriology resu lts, Staphylococcus aureus,
sen sitive to n early all an tibiotics, grew in th e cu ltu re.
Clin dam ycin w as con tin u ed in traven ou sly or 10 days
accordin g to th e h ospital gu idelin es. A ter 10 days, th e an -
tibiotic th erapy w as con tin u ed orally or 1 w eek a ter CRP
level h ad n orm alized.
Th e u rth er clin ical evolu tion an d ollow -u p w as n ot prob-
lem atic. X-rays a ter 1 m on th sh ow ed th e bon e de ect
appeared larger an d th ere w as con cern abou t h ealin g
( Fig 20 .2 -8 ). X-rays 2 m on th s later dem on strated th at th e
de ect began to ll u p ( Fig 20.2-9 ). A ter 1 year, th e bon e
de ect w as com pletely h ealed an d th e bon e appeared to be
n orm al ( Fig 20 .2 -10 ). Fu n ction ally th e sh ou lder w as also
n orm al an d th e patien t w as pain ree.

a b
Fig 20 .2 -7 Im m obilization of the arm using a sling. Fig 20.2-8a b The rst follow-up x-rays show that the bone de fe ct is
large r than visualize d im m e diate ly postope rative ly. This could indicate
an ongoing active infe ction, but the clinical situation ( ie , no swe lling,
no pain) and the blood laboratory te sts ( ie , C-re active prote in le ve l
ne arly norm al) show that the re is no active proce ss and that this
re sorption is the norm al re action of the bone .
a AP vie w.
b Late ral vie w.

440 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo
9 Pit fa lls
Even w h en all sym ptom s su ggested an osteom yelitis (ie,
pain , sw ellin g, ever, an d abscess), th ose sym ptom s w ere
m isin terpreted an d th e diagn osis w as delayed or a lon g
tim e; th e clearly abn orm al x-rays w ere in terpreted as n or-
m al (see Fig 20 .2 -1 ). In su ch cases, th ere are u n desirable
lon g-term resu lts, grow th problem s or m alu n ion [13].
a b
Fig 20 .2 -9 a b The se cond follow-up x-rays afte r 3 m onths show
progressive healing with normal bone formation and decreasing defect.
a AP vie w.
b Late ral vie w.
10 Pe a rl
In th ese n eglected cases th e resu lt can be com plication s,
su ch as septicem ia an d lon g-term grow th problem s. How -
ever, exten sive exploration an d debridem en t o th e bon y
abscess resu lted in th ese problem s bein g avoided an d th ere
w as a u n ction al an d an atom ically n orm al ou tcom e ( Fig
20 .2 -10 ). Th e sh ou lder m obility w as sym m etrical, an d th e
h ead o th e h u m eru s as w ell as th e join t appeared n orm al.
11 Re fe re n ce s
1. Ilh a rre b o rd e B. Sequ elae o ped iatric osteoarticu lar in ection .
Orthop Traumatol Surg Res. 2015 Feb;101(1 Su ppl):S129 137.
2. Nd u a gu b a AM, Flyn n JM, Sa n ka r WN. Septic arth ritis o th e
elbow in ch ildren : clin ical presen tation an d m icrobiological
pro le. J Pediatr Orthop. 2016 Jan ;36(1):75 79.
3. Ca rm o d y O, Ca w le y D, Do d d s M, e t a l. Acu te h aem atogen ou s
osteom yelitis in ch ild ren . Ir Med J. 2014 Oct;107(9):269 270.
Fig 20 .2 -10 The follow-up x-ray
afte r 1 ye ar shows full re cove ry
with norm al bone structure .
441
 Se ct io n 3Case s
20 .2 Oste omye litis
of
the
proximal
humerus

442 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo
20 .3 Po s to p e ra tive o s te o m ye litis o f th e tib ia
The d dy Slongo
1 Ca s e d e s crip t io n
A 14.5-year-old girl su stain ed a ski in ju ry (ie, torsion o th e
leg w h en th e righ t ski w as xed). Th is in ju ry resu lted in a
closed, lon g spiral isolated tibial ractu re w ith a lon g bu t-
terf y ragm en t (AO Pediatric Classi cation 42tD/ 5.2). No
oth er in ju ries w ere presen t ( Fig 20.3 -1 ).
Th e ch ild w as tran s erred to a local h ospital or treatm en t.
Th e su rgeon per orm ed old- ash ion ed open redu ction an d
extern al xation (ie, w ide exploration an d a screw in every
h ole) an d platin g o th e tibia ( Fig 20 .3 -2 ).
a b
Fig 20 .3 -1a b Initial x-rays show a m inimally displace d and
not se ve re ly angulate d com m inute d isolate d tibial shaft fracture .
Since the bula is intact, a too rigid xation can cause he aling
proble m s e ve n in childre n. The re fore , nonope rative tre atm e nt
can also be discusse d.
a AP vie w.
b Late ral vie w.
A ter 5 days th e patien t w en t h om e. At th is tim e, accordin g
to th e girls m oth er, th ere was m arked sw ellin g an d th e wh ole
low er leg w as still pain u l. Over th e n ext 2 w eeks, th e ch ild
w as alw ays in pain w ith a low tem peratu re an d th e an terior
part over th e su tu re h ad an in creasin g h yperem ia. A ter 16
days sh e retu rn ed to th e su rgeon or a postoperative visit.
a b
Fig 20 .3 -2 a b Postope rative x-rays show a dynam ic
com pre ssion plate oste osynthe sis in a rigid fashion; in addition
the re are thre e lag scre ws for the butte r y fragm e nt. To m ake
such an anatomical oste osynthe sis with absolute stability, a
wide approach is ne ce ssary.
a AP vie w.
b Late ral vie w.
443
 Se ct io n 3Case s
20 .3Postoperative
oste omye litis
of
the
tibia

1.1 Clin ica l e xa m in a t io n 16 d a ys p o s t o p e ra t ive ly
Th e patien t h ad a w eaken ed con dition w ith elevated tem -
peratu re (~38 C), severely sw ollen low er leg, severe local
h yperem ia, an d secretion rom th e distal w ou n d. Blood
testin g dem on strated a w h ite blood cell cou n t > 15,000 cells/
L. A n ew x-ray w as taken w h ich added n o n ew in orm ation
( Fig 20 .3 -3 ). Th e decision w as m ade to start oral an tibiotics
an d revisit th e case in 35 days.
Over th e n ext 3 w eeks th e situ ation did n ot m arkedly ch an ge.
A ter startin g an tibiotics, th e sw ellin g an d local h yperem ia
decreased. A ter 10 days o an tibiotic th erapy, all th e sym p-
tom s w ere slow ly retu rn in g. So 5 w eeks a ter th e operation
th e atten din g su rgeon ordered a com pu ted tom ograph ic
scan ( Fig 20.3 -4 ). Th e decision w as m ade to con tin u e an ti-
biotics becau se th ere w ere n o obviou s sign s o osteom yelitis
or bon e sequ estru m .
A ter 7 w eeks, tw o blisters h ad orm ed in th e distal th ird o
th e w ou n d ( Fig 20.3-5 ). In addition , a n ew x-ray w as taken
sh ow in g som e callu s orm ation in th e proxim al ractu re
region , with n o h ealin g reaction in th e distal part ( Fig 20.3-6 ).
At th is tim e, th e ch ild w as sen t to th e au th ors clin ic.

a b c
Fig 20 .3 -3a c Fig 20 .3 -4 In this 2-D
a b Afte r 16 days ne w x-rays we re take n be cause the patie nt com pute d tom ographic scan
re turne d with swe lling and pain. The radiologist and the cut the re sorption zone is
surge on inte rpre te d the se ne w picture s as unobtrusive . But m uch cle are r; this was initially
som e re sorption and irre gularity on the late ral corte x is visible . m isinte rpre te d.
c The de taile d vie w cle arly shows this re sorption (arrows).

444 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo
1.2 Clin ica l e xa m in a t io n o n p re s e n t a t io n a t t h e
a u t h o r s clin ic
Th e 14.5-year-old girl w as 7 w eeks postoperative w ith n o
ever. Th e local situ ation sh ow ed sligh t sw ellin g, sligh t
h yperem ia, th e proxim al w ou n d h ad h ealed, an d th e distal
w ou n d h ad tw o istu las w ith clou dy liqu id drain in g
( Fig 20.3-5 ).
Fig 20 .3 -5 The rst clinical picture of the local situation showing
the bliste rs and swolle n distal lowe r third of the le g.
1.3 Ad d it io n a l e xa m in a t io n
Wh en th e ch ild w as sen t to th e au th ors clin ic, th e prior
exam in ation s an d radiological in vestigation s w ere obtain ed.
Togeth er w ith th e in orm ation on th e clin ical situ ation
( Fig 20.3-5 ) th ere w as n o n eed or u rth er exam in ation s.
A bon e scan cou ld h ave been discu ssed, bu t in ch ildren a
n ecrotic or avital bon e is rare an d du rin g th e plan n ed revision
it can be ch ecked clin ically.
a b
Fig 20 .3 -6a b Be cause of a swolle n,
painful le g and bliste rs in the distal third
a ne w x-ray was take n afte r 7 we e ks: in
the uppe r part the re is som e he aling but
in the distal part progre ssive re sorption
is a sign of infe ction.
a AP vie w.
b Late ral vie w.
445
 Se ct io n 3Case s
20 .3Postoperative
oste omye litis
of
the
tibia

2 In d ica t io n 5 Su rgica l d e b rid e m e n t

Th is w as an in ected plate osteosyn th esis w ith in su cien t
m an agem en t o th e situ ation . In addition , th ere w ere tw o
stu las w ith pu ru len t drain age. Th ere ore, th ere w as a clear
in dication or im m ediate revision su rgery.
On ce th e plate w as rem oved, it w as clear th at th e irst
su rgeon h ad stripped n early all th e periosteu m rom th e
tibia. Su rrou n din g 50% o th e len gth o th e plate w as a large
cavity o in ection w ith pu s, an d on ly in th e proxim al h al
h ad th e so t tissu e adh ered to th e plate.

3 Pre o p e ra t ive p la n n in g
1. Rem oval o th e plate ollow ed by local debridem en t
an d rem oval o all poten tial dead bon e.
2. Fixation w ith a rin g xator an d clean in g o th e w ou n d
w ith n egative-pressu re w ou n d th erapy (NPWT) closu re
dressin g.
Th e goal is to treat th e in ection an d close th e w ou n d as a
secon dary h ealin g w ith ou t addition al su rgery, an d to x th e
n on u n ion w ith th e rin g xator u p to com plete bon e h ealin g,
w ith n o ch an ge to xation .
Th ree sm all, ree sequ estrae w ere rem oved w h ich w ere n ot
seen on th e x-ray or th e com pu ted tom ograph ic scan . Th e
large bu tterf y spiral w edge w as n ot in con tact w ith th e
periosteu m an d w as w h ite.
Sin ce th e m ain proxim al an d distal ragm en ts h ad good blood
su pply, th ey w ere le t in situ . In ch ildren th is is perm itted
becau se o th e in creased ability or rapid h ealin g an d revas-
cu larization .

4 Su rgica l a p p ro a ch

1. Th e patien t is in su pin e position w ith n o tou rn iqu et

w ith preparation an d drapin g o th e righ t leg above th e
kn ee.
2. Reopen in g o th e w ou n d alon g th e rst in cision an d
excision o th e stu lae.
3. Rem oval o th e plate becau se th e screw s w ere still w ell
xed in th e proxim al part, h ow ever, alm ost all distal
screw s w ere loosen ed.

446 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo

6 Te m p o ra r y a n d d e fin it ive fixa t io n
1. Placem en t o a rin g xator or good stabilization allow s
or u ll w eigh t bearin g on th e on e h an d an d biological
distraction / com pression on th e oth er h an d.
2. Application o an NPWT dressin g or w ou n d closu re.
To apply su ch a dressin g in com bin ation w ith an
extern al xator a special liqu id ru bber w as u sed
arou n d th e pin s to ach ieve an airtigh t closu re ( Fig 20.3-7 ,
Fig 20.3-8 , Fig 20 .3 -9 ).
Du e to th e patien ts age th ere w as h igh h ealin g poten tial so
th e goal w as to h ave a stable an d dyn am ic xation th at cou ld
be u sed to assist h ealin g. Fig 20.3 -10 sh ow s th e postoperative
x-ray w ith th e rin g xator in situ ; th e sm all bon e de ect is
visible rom w h ere th e sm all sequ estra w as rem oved, m ost
clearly visible on th e lateral view Fig 20 .3 -10a .

Fig 20 .3 -7 Clinical situation afte r Fig 20 .3-8 Ble e ding bone afte r re m oval Fig 20.3-9 Situation during the rst
de bride m e nt and wound cle aning and of the thre e small se que strae . One half-pin ne gative -pre ssure wound the rapy closure
be fore application of ne gative -pre ssure was inse rte d dire ctly into the large butte r y e xchange .
wound the rapy closure . In the re gion whe re se gm e nt to hold it in place .
the stulas and bliste rs we re re se cte d the
wound was le ft ope n. This was a good
approach for the ne gative -pre ssure wound
the rapy closure .

a b
Fig 20 .3 -10a b Som e days afte r plate re m oval and de bride m e nt:
the ring xator is xing the fracture .
a On this late ral vie w the bone de fe ct on the ante rior aspe ct is
cle arly visible .
b The AP vie w shows a good alignm e nt of the fracture and
fragm e nts.

447
 Se ct io n 3Case s
20 .3Postoperative
oste omye litis
of
the
tibia

7 Po s t o p e ra t ive m a n a ge m e n t Over th e n ext 3 w eeks, th e NPWT treatm en t w as con tin u ed

Th e rst NPWT dressin g w as le t in place or 3 days be ore
it w as ch an ged. Du rin g th is sh ort tim e th ere w as a clear
im provem en t; th e base o th e w ou n d an d th e bon e appeared
red an d h ealth y, w h ich w as eviden ce or revascu larization
( Fig 20.3-11 ).
Th e ch ild was position ed in th e bed or w h eelch air w ith th e
leg in an elevated position . Becau se o th e du ration o sym p-
tom s an d th e len gth o tim e or wh ich th e ch ild h ad taken
an tibiotics, th e pediatric in ection specialist advised stoppin g
th e oral an tibiotics [13]. Th e ocu s was on th e local treatm en t.
Th e circu lation cou ld be stim u lated an d accelerated w ith
wou n d care. Th is is su cien t m an agem en t in a h ealth y ch ild.
an d th ere w as rapid h ealin g an d closu re o th e w ou n d. At
th is tim e th e ch ild w as allow ed to w alk w ith partial w eigh t
bearin g as tolerated ( Fig 20 .3-12 , Fig 20 .3 -13 ).
A ter 4 w eeks th e ch ild w as disch arged rom th e clin ic in a
good gen eral con dition . Fu rth er ollow -u p care w as pro-
vided by th e h om ecare n u rse. Th e ch ild w as ollow ed u p in
th e clin ic every 2 w eeks.
Six w eeks a ter begin n in g treatm en t in th e au th ors clin ic,
th ere w as good h ealin g an d in tegration o th e ree bu tterf y
ragm en t. In addition , good callu s orm ation w as also visible
( Fig 20.3-14 ).

Fig 20 .3 -11 De taile d vie w of
whe n the ne gative -pre ssure wound
the rapy closure was e xchange d the
se cond tim e . To che ck the he aling
progre ss, a scale was always use d
for photographic docum e ntation.
The skin prote ction for the ne gative -
pre ssure wound the rapy closure
dre ssing is also visible .
Fig 20.3 -12 Clinical situation afte r 3 we e ks of
ne gative -pre ssure wound the rapy closure . At this
point the the rapy was stoppe d. Now the patie nt
was allowe d and stim ulate d to walk be aring full
we ight.
Fig 20.3-13 One we e k afte r the ne gative -
pre ssure wound the rapy closure was stoppe d,
on the one hand the wound has re duce d in size ,
but on the othe r hand, the re is som e se cre tion.
The bacte riological e xam ination (ste rile
se cre tion) showe d no infe ction.

Fig 20.3 -14a b The se ne w x-rays take n 6 7

we e ks afte r the author's tre atm e nt show a
progre ssive consolidation and inte gration of the
fragm e nt, and no ne w re sorption. The fracture line
be twe e n the main distal fragm e nt and the long
butte r y fragm e nt is still pre se nt.
a AP vie w.
a b b Late ral vie w.

448 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo
8 Ou t co m e
Th e x-rays a ter 10 w eeks ( Fig 20 .3 -15 , Fig 20 .3 -16 ) sh ow ed
su cien t h ealin g an d th e skin con dition w as also good,
w h ich m ean t a com pletely h ealed w ou n d, n o sw ellin g, an d
n o sign o in ection .
a b
Fig 20 .3 -15 a b Te n we e ks afte r application of the ring xator
the re re m ains a line in the distal part of the fracture . But now m ore
bridging callus is visible , e spe cially on the late ral side . The ring xator
was re m ove d and re place d by a custom -m ade be rglass splint.
a AP vie w.
b Late ral vie w.
a b
Th e rin g xator w as rem oved w ith sedation an d a u n c-
tion al, rem ovable berglass splin t w as applied.
Tw o w eeks later, a n ew x-ray w as per orm ed to ch eck or
ractu re or sign s o in stability ( Fig 20.3 -17 ).
a b
Fig 20 .3 -16 a b Thre e days afte r the xator
was re m ove d the patie nt e xpe rie nce d som e
pain, so a ne w x-ray was take n. Howe ve r, the re
was no diffe re nce to the x-ray with the xator
in place . The poste rior consolidation was be tte r
than the ante rior consolidation.
a AP vie w.
b Late ral vie w.
Fig 20 .3 -17 a b Two we e ks late r, a ne w x-ray was pe rform e d to
che ck for fracture or signs of instability. The re was no ne gative
e volution and he aling was occurring.
a AP vie w.
b Late ral vie w.
449
 Se ct io n 3Case s
20 .3Postoperative
oste omye litis
of
the
tibia
Th e ch ild w as w alkin g w ith ou t an y problem s w ith th e
rem ovable splin t. Th ere w as n o pain an d n o oth er path o-
logical sign s. Th e x-ray 6 m on th s a ter in itial revision sh ow s
a slow bu t con tin u ou s con solidation an d rem odelin g. On ly
a sm all ssu re on th e an terior cortex w as visible. Visu ally
an d radiologically th ere is a sligh t recu rvatu m ( Fig 20 .3 -18 ).
At th is tim e, sports activities w ere allow ed.
a b
Fig 20 .3 -18 a b He aling was progre ssing
we ll 2 .5 m onths late r; the re was no local
pain and the wound was comple tely close d.
The patie nt was allowe d to do low-im pact
sports activitie s like jogging, swimm ing,
and bicycling.
a AP vie w.
b Late ral vie w.
450
Th e u rth er ollow -u p visits w ere all u n even t u l ( Fig 20 .3 -19 ,
Fig 20 .3 -20 ). Th e ch ild retu rn ed to n orm al u n ction an d
activity. Th ere w as n o leg-len gth discrepan cy visible. Cos-
m etically, th e patien t an d th e paren ts w ere also h appy.
Follow -u p visits ceased a ter 2 years.
a b
Fig 20 .3 -19 a b The ne xt x-rays and
clinical controls we re made 5 m onths late r.
The patie nt had no proble m s. The re is
now full consolidation e ve n though a ne
fracture line is visible
a AP vie w.
b Late ral vie w.
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
The ddy Slongo

9 Pit fa lls 11 Re fe re n ce s

Th e in itial osteosyn th esis w as in appropriate or th is 1. [No a u t h o rs lis t e d ]. Will oral an tibiotics su ce in

ractu re an d given th e age o th e ch ild; th is ractu re
cou ld also h ave been treated w ith a n orm al, w ell-
m olded lon g-leg plaster cast, h ealin g w ith in 6 w eeks.
Th e tech n iqu e o th e plate osteosyn th esis does n ot
correspon d to todays biological speci cation s. For a
ch ild, th is type o xation is too rigid.
Th e sign s o th e in ection w ere m isin terpreted an d
recogn ized too late.
In adequ ate th erapy or th e in ection w as provided.
osteom yelitis? Arch Dis Child. 2015 Mar;100(3):278.
2. Ke re n R, Sh a h SS, Sriva s t a va R, e t a l. Com parative e ectiven ess
o in traven ou s vs oral an tibiotics or postd isch arge treatm en t o
acu te osteom yelitis in ch ildren . JA MA Pediatr. 2015
Feb;169(2):120 128.
3. Sch ro e d e r AR, Ra ls t o n SL. In traven ou s an tibiotic du ration s or
com m on bacterial in ection s in ch ild ren : wh en is en ou gh
en ou gh? J Hosp Med. 2014 Sep;9(9):60 4 6 49.

10 Pe a rls

Becau se o th e good h ealth o th e ch ild, th e in ection

cou ld be solved w ith in a sh ort tim e.
Th e acceptan ce o th e rin g xator by th e ch ild an d h er
paren ts led to a good ou tcom e.
Th ere w as early solid con solidation an d h ealin g
w ith ou t u n ction al restriction .

a b
Fig 20.3-20a b The last follow-up x-ray after
2 ye ars shows full re m ode ling and the start
of tibial re canalization. Radiologically the re is
slight varus in the AP vie w (a ) and re curvation
in the late ral vie w ( b ). Clinically this was not a
proble m and the patie nt and he r pare nts we re
happy.

451
 Se ct io n 3Case s
20 .3Postoperative
oste omye litis
of
the
tibia

452 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo

20 .4 Os te o m ye litis/ s e p tic a rth ritis o f th e p roxim a l

fe m u r in a to d d le r
The d dy Slon go

1 Ca s e d e s crip t io n Th e pediatrician re erred h im to th e pediatric clin ic o th e

A ter 10 days o su b ebrile tem peratu re, a m oth er n oticed
th at h er 16-m on th -old boy n o lon ger w an ted to bear w eigh t
on th e righ t leg. Sh e w aited an oth er day an d w h en th e
situ ation did n ot im prove, th e m oth er took th e toddler to
a pediatrician . In th e m ean tim e, h is con dition h ad w orsen ed
w ith a tem peratu re over 38 C.
Th e pediatrician diagn osed ph aryn gitis an d sw ollen lym ph
n odes. Th e m oth er reported later th at th e pediatrician did
n ot exam in e th e legs or h ip o h er ch ild. He prescribed
m edication to redu ce th e ever an d an an tibiotic.
Over th e n ext 2 days th e con dition rem ain ed u n ch an ged.
Th e m oth er reported to th e pediatrician th at th e boy exh ib-
ited severe pain w ith m ovem en t o th e righ t leg. A ter a n ew
con su ltation , th e pediatrician sen t th e toddler or a pelvic
x-ray. Th e diagn osis w as n orm al x-ray, n o path ology n oted
( Fig 20.4-1 ).
au th ors ch ildren s h ospital becau se o th is u n clear situ a-
tion . Age, sym ptom s, an d pseu doparalysis in th e absen ce
o n eu rological sign s (ie, m en in gitis) stron gly su ggest th at
th e toddler h as osteom yelitis or osteoarth ritis [1 ].
1.1 Clin ica l e xa m in a t io n 17 d a ys a ft e r t h e firs t
s ym p t o m s
Th e boy w as seen rst by a pediatrician at th e clin ic:
16-m on th -old toddler in severely redu ced con dition ,
n ot m ovin g h is righ t leg, passive m ovem en t pain u l,
sw ollen righ t th igh an d in gu in al region
Fever 39 C
Boy sh ows a septic con dition ; an im m ediate in traven ou s
an tibiotic th erapy (ce u roxim e) w as started [24]

Fig 20 .4 -1 The initial x-ray take n by a private radiologist. The

diagnosis was a normal hip. But the re are diffe re nt pathological
signs in the right proximal fe m oral re gion and in the hip. Wide r
joint space ( black arrows), lowe r transpare ncy of the soft
tissue in the proximal fe mur (white arrows), and irre gular bone
structure .

453
 Se ct io n 3Case s
20 .4Oste omye litis/ se ptic
arthritis
of
the
proximal
fe mur
in
atoddler

1.2 Ad d it io n a l e xa m in a t io n Th e pediatrician requ ested a son ograph y ( Fig 20 .4 -3 ). Th e

Blood testin g: w h ite blood cell cou n t m ore th an 40,000/ L
an d C-reactive protein level n early 200 m g/ L. A blood
cu ltu re w as per orm ed.
X-rays o th e righ t h ip an d em u r ( Fig 20 .4 -2 ) revealed a
severe, progressive destru ction o th e u pper em u r an d an
exten ded join t space.
in terpretation o th e son ograph y w as n ot absolu tely clear;
th e radiologist reported an in ection w ith pu s. Th ere ore, a
bon e scan w as also per orm ed sh ow in g a h yperper u sion in
th e w h ole proxim al em oral part an d in th e h ip join t
( Fig 20.4-4 ).
Th e toddler w as sen t to pediatric su rgery [5].

A con su ltation togeth er w ith th e pediatric su rgeon w as

arran ged: th e su rgeon decided to explore th e proxim al em u r
an d h ip join t. For h im n o addition al in vestigation s w ere
in dicated; h is diagn osis w as n eglected osteom yelitis/ septic
arth ritis.

a b

a b
Fig 20 .4 -2 a b The se x-rays we re take n 17 days afte r onse t of
sym ptom s. The re is a progre ssive de struction of the uppe r fe m ur and
an e xte nde d joint space .
c d
Fig 20 .4 -3 a d The inte rpre tation of this sonography was dif cult
be cause the majority of the capsule was de stroye d so the cle ar
structure of the joint and the capsule was m isinte rpre te d. An obvious
e ffusion in the hip joint was not se e n.

454 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo

2 In d ica t io n 4 Su rgica l a p p ro a ch

From a su rgical poin t o view , th e in dication or an in ter- To m in im ize addition al su rgical dam age th e au th or decided
ven tion w as absolu tely n ecessary [2]; on ly an exploration , to per orm tw o separate approach es: a classic lateral ap-
evacu ation o pu s, an d irrigation an d drain age o th e join t proach or th e em u r, an d an in gu in al in cision an d blu n t
can preven t a total disaster, su ch as avascu lar n ecrosis (AVN) dissection in th e m edial w in dow or th e h ip [6].
o th e h ip an d th e proxim al em u r. How ever, th ere w as a
h igh risk th at AVN cou ld n ot be preven ted a ter su ch a lon g
tim e. Risks w ere discu ssed in detail preoperatively w ith th e
paren ts.

3 Pre o p e ra t ive p la n n in g

Th e m ost di cu lt step in th e preoperative plan n in g w as

plan n in g th e correct approach . In addition , it w as im portan t
to discu ss with th e paren ts th e wh ole postoperative procedu re:
lon g-term in traven ou s an tibiotic th erapy, th e possibility o
u rth er operation s, an d u n ction al de cit.

a b
Fig 20 .4 -4 a b On the se unne ce ssary bone scans the sam e inform ation is shown as se e n on the x-ray.
a Ante rior vie w.
b Poste rior vie w.

455
 Se ct io n 3Case s
20 .4Oste omye litis/ se ptic
arthritis
of
the
proximal
fe mur
in
atoddler

5 Su rgica l d e b rid e m e n t appeared ligh t gray in color, in dicatin g a n u trition problem .

Step 1: Lateral approach
A lateral in cision w as m ade rom th e tip o th e greater
troch an ter u p to th e m iddle o th e th igh , th en a classic open -
in g o th e ascia an d su bvastu s lateralis approach to th e
em u r.
A ter open in g th e ascia, a lot o pu s w as evacu ated o erin g
a spon tan eou s view o th e lateral em u r. Th e dissection o
th e m u scle w as don e by th e abscess. Th e periosteu m w as
also destroyed.
Th e em oral h ead w as th en per orated w ith a sh arp n eedle
an d n o bleedin g w as visible. An irrigation drain w as th en
in stalled in th e h ip join t or 48 h ou rs.
6 Te m p o ra r y a n d d e fin it ive fixa t io n
A ter th e operation th e ch ild w as position ed an d xed in an
abdu ction brace (Lrrach er splin t) th at is n orm ally u sed to
treat h ip dysplasia ( Fig 20.4-6 ). Th is xation w as applied both
to redu ce pain an d to stabilize th e h ip in a cen tered position .

Th en th e em u r w as open ed u sin g a lateral bon y w in dow 7 Po s t o p e ra t ive m a n a ge m e n t

o 1 x 5 cm . Th orou gh irrigation w as per orm ed. Tw o drain s
w ere placed: on e in th e m edu llary can al, on e su b ascially. Over th e n ext 48 h ou rs th e h ip join t w as irrigated over th e
Th en th e skin w as closed loosely. drain ; th e lateral tw o drain s provided evacu ation o th e pu s.

Step 2: In gu in al approach ( Fig 20 .4 -5 )
Usin g an in gu in al in cision , ie, distal alon g th e in gu in al
ligam en t, th e ascia w as prepared. A ter open in g th e ascia,
exposu re w as ach ieved betw een th e vessels on th e m edial
side an d th e psoas m u scle w ith th e n erve on th e lateral side
ollow in g th e path o th e abscess. Th e capsu le o th e h ip
join t w as com pletely destroyed. In ten sive irrigation o th e
h ip join t w as per orm ed (u sin g 1 L o f u id) w h ich w as
su blu xed by a gen tle traction on th e leg. On ce th e em oral
h ead w as cleared an d clean , th e cartilage w as visible an d
An tibiotics w ere adm in istered or 14 days th rou gh a cen tral
vein cath eter ( Ta b le 20 .4 -1 ) [4]. Th en or 4 m ore w eeks oral
an tibiotics w ere given u n til all blood param eters w ere n or-
m alized.
Th e Lrrach er splin t w as rem oved a ter 4 w eeks an d th e
toddler started to w alk. Th e x-ray ( Fig 20 .4 -7 ) a ter 5 w eeks
sh ow s a de ect on th e proxim al em u r an d som e asym m etry
in th e h ip join t.

Fig 20 .4 -5 Clinical intraope rative vie w of a toddle r's
le ft inguinal re gion. The 4 5 cm incision is made
along the inguinal skin line . The n the m e dial window
is use d in a m odi e d way: the two ve sse ls are m e dial,
the fe m oral ne rve toge the r with the psoas m uscle are
late ral.
Fig 20 .4 -6 Postope rative ly the patie nt was
im m obilize d in a m obile abduction brace ,
a Lrrache r splint, which allows conce ntric
stable m ove m e nt of the hip joint.

456 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo

Diagnosis Pathogen First choice therapy (single shot and interval) Duration, days Maximum dosage Alternatives/remarks
Osteomyelitis acute S aureus Age < 5 years IV> 710 Amoxicillin clavulanate
S pyogenes Cefuroxime 50 mg/kg every 8 h IV IV+ orally 4.5 g 50 mg/kg every 8 h IV
H influenzae Cefuroxime axetil 30 mg/kg 28
Kkingae every 8 h orally

Age > 5 years

Clindamycin 15 mg/kg every 6 h IV IV> 710 1.8 g Amoxicillin clavulanate
Clindamycin 15 mg/kg IV+ orally 30 mg/kg every 8 h orally
every 8 h orally 28
Osteomyelitis chronic Staphylococcus Always interdisciplinary consultation between surgeon and
Enterobacteriaceae infectious diseases specialist

Therapy started after biopsy and culture

Arthritis acute S aureus Age < 5 years IV> 7 Amoxicillin clavulanate
S pyogenes Cefuroxime 50 mg/kg every 8 h IV IV+ orally 4.5 g 50 mg/kg every 8 h IV
Neisseriaceae Cefuroxime axetil 50 mg/kg every 8 h orally (sic!) 21
Kkingae
Age > 5 years
Clindamycin 15 mg/kg every 6 h IV
Clindamycin 15 mg/kg every 8 h orally 1.8 g Amoxicillin clavulanate
Gonorrhea ceftriaxone 2 g every 24 h IV> 7 30 mg/kg every 8 h orally
IVx 7 days IV+ orally
21
Lyme arthritis Borrelia burgdorferi Ceftriaxone 80 mg/kg every 24 h IV 14 2g Amoxicillin 20 mg/kg
(mostly gonarthritis) every 8 h orally 28 days

Age > 8 years

Doxycycline 12 mg/kg
every 12 h orally x 28 days

Ta b le 20.4-1 Antibiotic the rapy of ske le tal infe ction according to age , diagnosis, and pathoge n.
Data translate d into English by the author and with pe rm ission from Schni M, Sim one tti G, Ae bi C, e ds. Be rne r Da te nbuch P dia trie . Ve rlag
Hans Hube r Hogre fe AG Be rn; 2015:355 .
Abbre viations: S a ure us, Sta phylococcus a ure us; S pyoge ne s, Sta phylococcus pyoge ne s; H in ue nza e, Ha e m ophilus in ue nza e; K kinga e,
Kinge lla kinga e; IV, intrave nous.

Fig 20 .4 -7 The 5 -we e k postope rative x-ray

de m onstrate s the initial as we ll as the ope rative bone
de fe ct but no ne w de struction.

457
 Se ct io n 3Case s
20 .4Oste omye litis/ se ptic
arthritis
of
the
proximal
fe mur
in
atoddler

8 Ou t co m e In x-rays Fig 20.4-9 , Fig 20.4-10 , an d Fig 20.4-11 both th e positive

Over th e n ext ew m on th s th e ch ild developed n orm ally
an d w as w alkin g w ith ou t a lim p. Th e rst real ollow -u p
x-ray w as taken 6 m on th s a ter su rgery. At th is tim e, th ere
w as n o sign o AVN an d th ere w as good h ealin g o th e prox-
im al em u r. A typical ph en om en on th e h ead w ith in th e
h eadw as seen as a good sign as n ew bon e w as orm in g
arou n d th e origin al ossi cation cen ter o th e h ead, bu t also
th e begin n in g o a coxa m agn a ( Fig 20 .4 -8 ).
an d n egative developm en ts over th e n ext 9 years can be
seen .
Th ese ch an ges w ere observed: in creased sh orten in g o th e
em oral n eck, developm en t o a f at an d w ide em oral h ead
(bu t still w ell con tain ed), overgrow th o th e greater tro-
ch an ter, an d som e reaction on th e acetabu lar side. Th e join t
space at th is tim e w as still n orm al.

In prin ciple it w as pleasin g to see th is positive evolu tion o

th e h ip. Fu rth er ollow -u p exam in ation s are absolu tely
n ecessary.

Fig 20 .4 -8 The 6 -m onth postope rative
x-ray shows a spe cial phe nom e non: the
he ad within the he ad sign around the
old he ad. This m e ans that at the tim e of
the infe ction around the he ad ne w bone
form ation is visible as a circle . Fe m oral
he aling is also visible .
a b
Fig 20 .4 -9a b X-rays take n 4 ye ars postope rative ly.
a A good situation: no sign of avascular ne crosis, inte gration of the he ad within the he ad
sign, wide joint space , and good fe m oral bone consolidation.
b The be ginning of som e articular re action is visible .

Fig 20 .4 -10 X-ray take n 6 ye ars
postope rative ly shows a at fe m oral he ad but
sphe rical and congrue nt to the ace tabulum is
a slight sign of a transie nt avascular ne crosis.
The situation is sim ilar to the e volution of a
Pe rthe s dise ase . The fe m ur appe ars ne arly
norm al.
Fig 20.4-11 X-ray take n 8 ye ars
postope rative ly de m onstrate s a pre mature
closure of the fe m oral he ad physis but still a
sphe rical containm e nt; the gre ate r trochante r
ove rgrowth proxim ally sim ulate s a coxa vara.

458 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo

At 11 years, 9.5 years a ter th e in ection an d su rgery, th e a sm aller join t space is visible, a lateralization o th e em oral
boys situ ation w orsen ed an d h e developed severe h ip pain . h ead, an d in addition som e reaction on th e acetabu lar side.

Th e u n ction w as poor an d th e ch ild w as lim pin g, th e righ t
leg w as 2 cm sh orter th an th e le t leg.
X-ray an d clin ical sym ptom s w ere typical or a m ixed in -
traarticu lar an d extraarticu lar im pin gem en t by com pression
o th e m in or glu teal m u scle betw een h igh greater troch an ter
an d acetabu lu m ( Fig 20.4-12 , Fig 20.4-13 ). On th e oth er side
At th is tim e a su rgical h ip dislocation w as per orm ed or
in spection o th e h ip join t an d to per orm a relative em oral
n eck len gth en in g [7, 8 ]. In traoperative n din gs w ere severe
dam age o th e labru m , dam age o th e articu lar cartilage in
an area o 2 cm x 0.5 m m betw een 10 an d 2 oclock
( Fig 20.4-14 ).

Fig 20 .4 -12 Be twe e n 8 and 9 ye ars
postope rative ly the fe m oral he ad starte d to
m igrate late rally and proximally; the tip of
the gre ate r trochante r is now at the le ve l of
the late ral ace tabular rim . At this tim e the
child had rapidly incre asing hip pain. The two
re asons for this are dam age to the late ral
and ante rior ace tabular rim and labrum ,
and an im pinge m e nt of the m inor glute al
m uscle be twe e n the gre ate r trochante r and
ace tabulum .
Fig 20 .4 -13 The full le g-le ngth standing
x-ray shows the re sulting le g-le ngth
de cit of 3 .5 cm; the le g axis is still
corre ct.
Fig 20.4-14 The situation was gre atly
im prove d 3 we e ks afte r surgical hip
dislocation and re lative fe m oral ne ck
le ngthe ning. The range of m otion was ne arly
sym m e trical to the le ft side , and the child had
no pain. This x-ray shows cle arly the e ffe ct
of the re lative ne ck le ngthe ning and that the
ne ck-shaft angle was always normal.

459
 Se ct io n 3Case s
20 .4Oste omye litis/ se ptic
arthritis
of
the
proximal
fe mur
in
atoddler

Un ortu n ately, at th is tim e, it w as n ot determ in ed th at th e As is eviden t in th e x-ray ( Fig 20 .4 -17 ), th e h ip cou ld be

h ip w as u n stable an d th e postoperative x-ray docu m en ts
th is in stability; th ere ore an abdu ction brace w as applied
or som e tim e ( Fig 20.4-15 ). How ever, a ter 6 w eeks, du e to
th e in stability, a triple pelvic osteotom y w as per orm ed
( Fig 20.4-16 ).
stabilized bu t th e process o destru ction w as progressin g
rapidly. Th e h ip join t n early disappeared an d in addition
th e h ip u n ction decreased bu t th e ch ild w as pain ree.

a b
Fig 20 .4 -15 a b Thre e we e ks afte r surge ry an x-ray for he aling asse ssm e nt was pe rform e d.
a The hip is no longe r stable .
b The adduction x-ray shows a re ce nte ring of the fe m oral he ad so an adduction brace was applie d.

Fig 20.4-17 Eight m onths afte r the triple

oste otomy, the child's hip is pain fre e . Howe ve r,
all plane s of m ove m e nt we re re duce d. In the
sagittal plane the e xion was still re lative ly
good up to 10 0 . Be cause of the le g-le ngth
discre pancy, in principle a bone le ngthe ning
should be pe rform e d. But in this particular
situation it would be proble matic be cause of the
high pre ssure on the hip joint during and afte r
le ngthe ning.
Fig 20 .4 -16 Five we e ks afte r the triple oste otomy
the hip is we ll cove re d but not optim ally ce nte re d;
the re is still som e late ralization. On the othe r hand,
the joint space has be com e narrowe r.

460 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

The ddy Slongo
9 Pit fa lls
Ign oran ce o th e typical sym ptom s at th e begin n in g
an d delay in th e th erapy can cau se an in itial AVN o
th e em oral h ead as w ell as n ecrosis o th e proxim al
em u r. In addition th e ch ild can develop septicem ia
w ith septic sh ock.
Aw aren ess o th e u n stable situ ation o th e h ip a ter th e
su rgical h ip dislocation an d th e relative em oral n eck
len gth en in g. Th e triple osteotom y sh ou ld be per orm ed
at th e sam e tim e.
From clin ical experien ce an d th e literatu re, on ce you
h ave su ch a n eglected in ectiou s situ ation , in itially on e
can treat th e problem . Th e destru ctive process is
on goin g bu t o ten rem ain s in active as lon g th ere is n o
n ew trau m a. Th e n ew in terven tion w ith th e triple
osteotom y w as su ch a trau m a an d reactivated th e
destru ctive process.
10 Pe a rls
In itially an d later, th ere w as n o AVN despite th e delay
in treatm en t.
Th e ch ild u n ction ed w ell over a lon g period.
11 Re fe re n ce s
1. Be rgd a h l S, Eke n gre n K, Erik s s o n M. Neon atal h em atogen ou s
osteom yelitis: risk actors or lon g-term sequ elae. J Pediatr
Orthop. 1985 Sep-Oct;5(5):56 4 568.
2. Ke re n R, Sh a h SS, Sriva s t a va R, e t a l. Com parative e ectiven ess
o in traven ou s vs oral an tibiotics or postd isch arge treatm en t o
acu te osteom yelitis in ch ildren . Ped iatric Research in In patien t
Settin gs Network. JA MA Pediatr. 2015 Feb;169(2):120 128.
3. Sch ro e d e r AR, Ra ls t o n SL. In traven ou s an tibiotic du ration s or
com m on bacterial in ection s in ch ild ren : wh en is en ou gh
en ou gh? J Hosp Med. 2014 Sep;9(9):604 609.
4. Slo n go T. M ikrobiologisch e Diagn ostik h u ger
In ektion sk ran k h eiten [M icrobiological d iagn osis o com m on
in ectiou s d iseases]. In : Sch n i M , Sim on etti G, Aebi C, eds.
Berner Datenbuch Pdiatrie. Bern : Verlag Han s Hu ber Hogre e
AG; 2015:355.
5. [No a u t h o rs lis t e d ] Will oral an tibiotics su ce in osteom yelitis?
Arch Dis Child. 2015 Mar;100(3):278.
6. Die ck m a n n R, Ha rd e s J, Ah re n s H, e t a l. [ Treatm en t o acu te
an d ch ron ic osteom yelitis in ch ildren .] Z Orthop Un all. 2008
May-Ju n ;146(3):375 380. Germ an .
7. Alb e rs CE, St e p p a ch e r SD, Sch w a b JM, e t a l. Relative em oral
n eck len gth en in g im proves pain an d h ip u n ction in proxim al
em oral de orm ities w ith a h igh -rid in g troch an ter. Clin Orthop
Relat Res. 2015 Apr; 473(4):1378 1387.
8. Le u n ig M, Ga n z R. Relative n eck len gth en in g an d in tracapital
osteotom y or severe Perth es an d Perth es-like de orm ities. Bull
N Y U Hosp Jt Dis. 2011;69 Su ppl 1:S6267.
461
 Se ct io n 3Case s
20 .4Oste omye litis/ se ptic
arthritis
of
the
proximal
fe mur
in
atoddler

462 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Zhao Xie
21 Tre a tm e n t o f in fe ctio n w ith lim ite d re s o u rce s
Zh ao Xie
1 In t ro d u ct io n
In ection is a problem th at does n ot discrim in ate betw een
patien ts based on socioecon om ic statu s, race, place o resi-
den ce, or eth n icity. As su ch , in ection s h appen all over th e
w orld a ter trau m a an d a ter su rgery. Som e patien ts w ill be
u n able to a ord treatm en t an d th e cost o n ew er tech n olo-
gies. In som e settin gs, th e in stitu tion treatin g patien ts w ith
in ection m ay lack th e ability to provide n ew er tech n ologies
or h igh -cost im plan ts. Non eth eless, th ere are sa e, basic
m eth ods o treatm en t available in su ch cases. Th is ch apter
ocu ses on th e u se o basic im plan ts or n o im plan ts an d
proven su rgical m eth ods or treatin g bon e in ection s.
2 Ba s ics
Su rgical debridem en t is a u n dam en tal prin ciple or m an age-
m en t o deep-bon e or so t-tissu e in ection . Basic prin ciples
in clu de establish in g th e diagn osis w h ich can o ten be don e
w ith care u l ph ysical exam in ation , a th orou gh h istory, plain
x-ray, an d n eedle aspiration o th e su spected area o in ection .
Som e in ection s are easy to diagn ose wh ereas oth ers m ay
requ ire m ore e ort to establish th e correct diagn osis. For
addition al in orm ation abou t diagn osis o in ection , see ch apter
7 Diagn ostics.
3 Et io lo g y
A u n dam en tal aspect o in ection treatm en t is u n derstan d-
in g th e etiology o th e in ection . Mu ch o th is u n derstan din g
can be gain ed by obtain in g a care u l h istory rom th e patien t
or h is or h er am ily ( Fig 21-1 ). Was th ere a trau m a? Was
th ere a pu n ctu re? Has th e patien t been ill? How lon g h ave
sym ptom s been presen t? Wh ere are th e sym ptom s located?
Has a ever been n oted? Is th ere local redn ess, sw ellin g, or
drain age rom th e area o con cern ? Has th e patien t been
exposed to oth ers w ith sim ilar problem s?
4 Wo u n d t yp e s
Most cases o bon e in ection w ill h ave an associated w ou n d.
Detailed m an agem en t o su ch w ou n d problem s is covered
in ch apter 13 So t-tissu e in ection s an d ch apter 14 Open
w ou n ds. For th e pu rposes o th is ch apter, th e au th or review s
basic m eth ods or m an agem en t o th e in ected extrem ity
in clu din g pre erred m an agem en t strategies.
Fig 21-1 Patie nt was re fe rre d to the authors hospital 18 m onths
afte r initial fracture of both lowe r lim bs in a m otor ve hicle crash. He
was diagnose d de nitive ly with a m e thicillin-re sistant Sta phylococcus
a ure us infe ction involving the distal part of the le ft fe mur. He was
pre viously tre ate d with vancom ycin intrave nously prior to transfe r to
the authors ce nte r. On e xam ination, he had he ale d surgical incisions
of his le ft thigh with active drainage , and a functional ankylosis of his
le ft kne e joint.
463
 Se ct io n 3Case s
21 Tre atment
of
infe ction
with
limite d
re source s

5 Sym p t o m s 6 Dia gn o s t ic w o rku p

Basic sym ptom s o in ection h ave been covered th orou gh ly
in th e previou s ch apters in th is book. Th e classic n din gs
o redn ess, in creased w arm th , pain , sw ellin g, an d drain age
are likely to be seen in m ost patien ts w ith bon e in ection .
Wh en treatin g patien ts w ith lim ited resou rces, patien ts w ill
o ten presen t late to receive care( Fig 21-2a ). Th is m ay be du e
to attem pted treatm en t at an oth er acility or or socioeco-
n om ic reason s. Beyon d com m on sym ptom s, scars an d skin
discoloration can o ten be seen in patien ts w ith a delay in
care ( Fig 21-2b ).
Th e u n dam en tal diagn ostic w orku p sh ou ld be con du cted
in all cases. Th is in clu des a detailed h istory an d ph ysical
exam in ation . Plain x-rays are requ en tly u se u l to u n derstan d
th e u n derlyin g bon e con dition an d th e presen ce o im plan ts,
oreign m aterial, an d sequ estered bon e ragm en ts. Needle
aspiration o th e su spected in ection site is w orth w h ile in
m an y cases.
6 .1 La b o ra t o r y
A periph eral w h ite blood cell (WBC) cou n t sh ou ld be avail-
able at m ost cen ters an d th e C-reactive protein (CRP) is
an oth er u se u l seru m m arker, i available. In cases w ith
active drain age, WBC cou n t an d CRP can be n orm al, or
m erely above th e lin e. Th is n din g m ay also be n oted in
n on drain in g in ection situ ation s.

Procalciton in is m ore sen sitive bu t WBC cou n t an d CRP are

ch eaper an d m ore appropriate w ays to con rm th e diagn osis
o in ection .

6 .2 Micro b io lo g y
Gram stain an d aerobic/ an aerobic cu ltu res are th e basic
m icrobiological stu dies th at sh ou ld be per orm ed in m ost
cases. Sequ estra are th e m ost valu able sam ples an d deep-
w ou n d cu ltu res are h elp u l to n d th e bacteria. Th e an ti-
a biotic h oliday can be u se u l be ore su rgery to im prove th e
ch an ce o an accu rate diagn osis. Postoperative an tibiotics
sh ou ld be adju sted w h en a de n itive bacterial cu ltu re h as
been obtain ed.

b a com pu ted tom ograph ic scan w ou ld be ben e cial. Ultra-
Fig 21-2a b Re sults of de laye d care .
a Unilate ral com m e rcial e xte rnal xator pre se nt on the le ft fe m ur
with ope n wound tre atm e nt.
b Scars and skin discoloration are note d as signs of a
chronically inde nt.
6 .3 Ra d io lo g y
Plain x-rays are th e m ost u se u l radiological stu dy to order
or th e patien t w ith a bon e in ection . Th ey can be u sed to
iden ti y th e location o sequ estra, th e xation o th e bon e
de ect, an d th e an atom ical type o osteom yelitis ( Fig 21-3 ).
Rarely, or a deep site o in ection , su ch as deep in th e pelvis,
sou n d, i available, is an oth er sim ple an d in expen sive m eth od
to localize a f u id collection .

464 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Zhao Xie

7 Ba s ics o f b o n e m a n a ge m e n t 7.2 Sp e cific m e t h o d s

Th e au th or dem on strates w ith ph otograph s several in n ova-
Th e basics o bon e m an agem en t w ill ollow rom an accu rate tive yet sim ple an d less costly m eth ods o m an agin g bon e
diagn osis. Th e diagn osis sh ou ld in clu de th e site o in ection ; in ection . Fig 21-4 sh ow s h ow to u se in tern al xation u n der
su spected exten t o in ection ; presen ce o a ractu re, o su rgical in ection circu m stan ce. Fig 21-5 dem on strates h ow to u se
im plan ts, o oreign m aterial; or sequ estered bon e bon e cem en t to tem porarily x th e bon e.
( Fig 21-3 ). All th ese diagn ostic criteria are critical to m ake a
precise su rgical plan , in clu din g th e ch oice o in cision , exten t
o bon y resection , m an agem en t o th e dead space, an d xation
o th e ractu re [1].

7.1 Prin cip le s

A u n dam en tal prin ciple o bon e in ection m an agem en t is
debridem en t o all n ecrotic bon e tissu e. Th is can som etim es
be di cu lt to determ in e. Bon e th at is bleedin g is u su ally
sa e to retain . Sequ estered ragm en ts o bon e or n ecrotic
bon e m aterial beh ave like oreign bodies an d sh ou ld be re-
m oved in all cases. Mech an ical debridem en t is th e best
m eth od to rem ove th e n idu s o in ection , an d th e exten t o
debridem en t a ects progn osis [2]. Addition ally, th e presen ce
o pu ru len t f u id w ill requ ire drain age in all cases. Th ere is
n o su bstitu tion or good su rgical bon e debridem en t in cases
in volvin g th e bon e.

a b

c d

Fig 21-3 X-ray shows an e xte rnal Fig 21-4 a d Inte rnal xation is not advise d whe n the infe ction is diagnose d clinically or bacte rio -
xator in situ with an e stablishe d logically. The se conse cutive picture s show a locking plate that was place d and wrappe d in antibiotic
nonunion, involucrum , and ce m e nt. The wrappe d plate is a com prom ise whe n a bulky e xte rnal xator is contraindicate d. The
se que strum of bone . patie nt e ve ntually had succe ssful wound he aling primarily and bone union ultimate ly.

465
 Se ct io n 3Case s
21 Tre atment
of
infe ction
with
limite d
re source s

7.3 Ma s q u e le t t e ch n iq u e
Th e Masqu elet tech n iqu e h as m an y orm s. Am on g th e sim plest
orm s is m eticu lou s bon e debridem en t ollow ed by place-
m en t o a polym eth ylm eth acrylate block spacer con tain in g
an tibiotic pow der in to th e bon e void le t by debridem en t.
Th is void can be m an aged su ccess u lly in m an y cases w ith
th e block spacer th at im parts som e stability to th e extrem ity,
directly treats th e in ection , an d prom otes a biological m em -
bran e to orm arou n d th e spacer ( Fig 21-6 ). A ter th e in ection
h as been con trolled, th e spacer can be care u lly rem oved
retain in g th e biologically in du ced m em bran e. Th e cavity
le t beh in d by th e spacer can th en be lled w ith au togen ou s
bon e gra t w h ich can be obtain ed rom th e patien ts pelvic
region ( Fig 21-7 ). Th is patien t acqu ired bon e u n ion 6 m on th s
a ter su rgery ( Fig 21-8 ) an d th e plate w as rem oved at h is n al
a b ollow -u p ( Fig 21-9 ).

Fig 21-6 The sam e patie nt as in Fig 21-5 . The white biological
c d m e m brane was care fully e xam ine d above the surface of the bone
ce m e nt.
Fig 21-5 a d This patie nt suffe re d from traum a with
an ope n fracture 8 ye ars ago. The initial de bride m e nt
was carrie d out and e xte rnal xation was place d. Afte r
the fourth day, the wound be cam e infe cte d. Re dne ss
and swe lling was obse rve d. The patie nt had anothe r
de bride m e nt and was discharge d due to socioe conom ic
re asons.
a b X-rays of the patie nts le ft le g whe n he rst was
adm itte d to the authors hospital afte r the surge ry.
Bacte rial culture was con rm e d of m e thicillin-
re sistant Sta phylococcus a ure us infe ction.
cd Antibiotic ce m e nt was place d afte r de bride m e nt
without any inte rnal or e xte rnal xation. The
ce m e nt can still stabilize the bone if the patie nt
coope rate s in situations of lim ite d re source s.

Fig 21-7 Autoge nous cance llous bone was grafte d from the iliac
cre st afte r the bone ce m e nt was re m ove d.

466 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Zhao Xie

7.4 De b rid e m e n t a n d ca s t in g / s p lin t in g
In som e cases bon e debridem en t can be per orm ed, su ch as
drain age o an in tram edu llary abscess w ith rem oval o se-
qu estered bon e. Follow in g w ou n d m an agem en t, th e leg
m ay be im m obilized in plaster u n til h ealin g h as occu rred.
7.5 Ext e rn a l fixa t io n m e t h o d s
Alth ou gh n ew com m ercial extern al xation is typically
costly, th ere are som e less costly altern atives available (see
Fig 21-2 a ).
For exam ple, th e lockin g com pression plate (LCP) works like
a u n ilateral extern al xator. Th e ch aracteristic an gle-stable
ram ew ork o th e LCP allow s or com plete con solidation o
th e ractu re an d does n ot depen d on th e riction betw een
plate an d bon e, bu t th e h oldin g orce betw een th e lockin g
screw an d th e cortical bon e [3]. Som e experts report th e
su ccess u l u se o an LCP as an extern al xator. Un like a
bu lky, tradition al extern al xation th e LCP is con cealed,
an d th u s m ore aesth etic, better tolerated, an d com patible
w ith activities o daily livin g ( Fig 21-10 ). Oth er advan tages
are u rth er ou tlin ed by Kloen [4], in clu din g stability, ease
o rem oval, an d less radiograph ic silh ou ette.
7.6 An t ib io t ic m a n a ge m e n t
An tibiotic m an agem en t is a u n dam en tal treatm en t m eth od
requ ired to h elp th e patien t overcom e h is or h er in ection .
Th is is covered in greater detail in ch apter 5 System ic
an tibiotics.

Fig 21-9 a b The plate

Fig 21-8 The patie nt can fully
was re m ove d at his nal
be ar we ight 6 m onths afte r surge ry.
follow-up 18 m onths afte r
a b surge ry.

a b c d
Fig 21-10 a d A fe male patie nt who suffe re d from posttraum atic oste omye litis with se gm e ntal de ad bone in the m idtibia.
a An e xte rnal xator is pre se nt on the m e dial aspe ct of the right tibia.
b c De ad bone was re m ove d using m e ticulous de bride m e nt. A Masque le t te chnique with a locking com pre ssion plate acting as an e xte rnal
xator was pe rform e d.
d The patie nt we nt on to bone union and he r plate was re m ove d in the surgical e xam ination room as an outpatie nt.

467
 Se ct io n 3Case s
21 Tre atment
of
infe ction
with
limite d
re source s

8 Co n clu s io n 9 Re fe re n ce s

In ection is a problem th at a ects patien ts rom all region s
o th e w orld an d people o all socioecon om ic classes. Becau se
som e cen ters an d som e patien ts h ave lim ited m ean s to treat
th ese in ection s, it is im portan t to be am iliar w ith som e
basic m eth ods or m an agem en t o th e in ection . Som e o
th ese tech n iqu es are tim e-h on ored an d h ave been u sed by
su rgeon s or m ore th an 100 years. Oth ers are n ew er, m ore
in n ovative m eth ods developed m ore recen tly. Th e au th or
h as presen ted th ese m eth ods in th e h ope th at th ey w ill be
u se u l to su rgeon s.
1. Mo t s it s i NS. Man agem en t o in ected n onu n ion o lon g bon es:
th e last decade (1996 2006). Injury. 2008 Feb;39(2):155 160.
2. Sim p s o n AH, De a k in M, La t h a m JM. Ch ron ic osteom yelitis. Th e
e ect o th e exten t o su rgical resection on in ection - ree
su rvival. J Bone Joint Surg Br. 2001 Apr;83(3):4 03 4 07.
3. Mille r DL, Go s w a m i T. A review o lockin g com pression plate
biom ech an ics an d th eir advan tages as in tern al xators in
ractu re h ealin g. Clin Biomech (Bristol, Avon). 2007
Dec;22(10):1049 1062.
4. Klo e n P. Su percu tan eou s platin g: u se o a lock in g com pression
plate as an extern al xator. J Orthop Trauma. 20 09
Jan ;21(1):7275.

10 Ack n o w le d gm e n t s

Jian Zh on g Xu , MD, an d Sh en g Pen g Yu , MD, con tribu ted

to th is ch apter.

468 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Glossary
Glossary
An t is e p t ic co ve ra ge
Coverage o a w ou n d w ith a m oist dressin g th at in clu des an
an tiseptic to be ch an ged each day w ith th e objective o pre-
ven tin g a su perin ection u n til th e w ou n d h as h ealed or th e
w ou n d is closed by su tu re or plastic su rgery.
Ar t h rit is , s e p t ic, in fe ct io u s
Stagin g as de n ed by Gch ter. Th ere are ou r stages based
on th e degree o severity.
Ba ct e ria , d ifficu lt-t o -t re a t
In term s o im plan t-associated in ection s, bacteria are con -
sidered di cu lt to treat i th ere are ew or n o an tibiotics
available th at can reliably elim in ate th e bacteria in clu din g
th ose bou n d w ith in th e bio lm . In oth er w ords, th e likeli-
h ood o su ccess u l treatm en t is n ot h igh u n less cu rative
an tibiotic th erapy is adm in istered ollow in g rem oval o th e
im plan t. Di cu lt-to-treat bacteria in clu de:
Ri am pin -resistan t staph ylococci
En terococci
Sm all-colon y varian ts (SCV) prim arily o staph ylococci
bu t also o Salmonella spp., Escherichia coli, Pseudomonas
aeruginosa
En terobacteria an d Pseudomonas aeruginosa th at are
resistan t to qu in olon es
Fu n gi
Meth icillin -resistan t Staphylococcus aureus (MRSA)
Van com ycin -in term ediate sen sitivity Staphylococcus
aureus (VISA)
Van com ycin -resistan t Staphylococcus aureus (VRSA)
Van com ycin -resistan t en terococci (VRE)
In ection s w ith u n kn ow n path ogen s th at h ave been clearly
detected in h istological tests are also di cu lt to treat.
Bio film
Microorgan ism s adh erin g to th e su r ace o im plan ts an d
w h ich are em bedded in a glycoprotein m atrix. Bacteria an d
u n gi in bio lm are m etabolically in active or h ave low m et-
abolic activity an d th u s less su sceptible to m ost an tibiotics.
Bro d ie a b s ce s s
An in tram edu llary abscess orm o prim ary ch ron ic osteo-
m yelitis. Th is is ch aracterized by a cen tral in f am m atory
ocu s th at is di eren tiated rom a broad, sclerotic bon e
m argin an d is u su ally localized in th e m etaph ysis, requ en t-
ly in th e tibia. It m ain ly a ects adolescen ts an d you n g adu lts
w ith an above-average im m u n e statu s.
Co a gu la s e re a ct io n
Meth od or di eren tiatin g staph ylococci: Staphylococcus
aureus, w h ich orm s a clot w h en m ixed w ith brin ogen -
con tain in g plasm a, is coagu lase-positive. Nearly all oth er
path ogen ic staph ylococci, eg, Staphylococcus epidermidis, are
coagu lase-n egative.
De b rid e m e n t
Debridem en t is u sed to redu ce th e bacterial cou n t at th e site
o in ection an d optim ize th e con dition s or an tibiotic th erapy.
Th e critical steps in clu de:
Rem oval an d replacem en t o th e im plan ts in cases o
h em atogen ou s in ection s lastin g lon ger th an 3 w eeks
or i an exogen ou s in ection a ter su rgery
Rem oval o th e tissu e su rrou n din g th e im plan t an d
n ecrotic bon e
Excision o o ten exten sive join t-capsu le protru sion s
an d stu las con tain in g detritu s
Adequ ate w ou n d drain age to preven t postoperative
h em atom a
Open syn ovectom y w ith join t in ection s (stages 3
an d 4)
Tissu e sam ples m u st be collected rom th e periprosth etic
area or im plan t bed
Gra m s t a in in g
Ch ristian Gram developed a stain in g tech n iqu e in w h ich
bacteria su rrou n ded by a th ick cellu lar w all com posed o
peptidoglycan s tu rn blu e (gram -positive bacteria) an d th ose
w ith on ly a th in cellu lar w all w ith an addition al ou ter lipid
m em bran e tu rn red (gram -n egative bacteria).
469
 Glossary

He a lin g in p e rip ro s t h e t ic in fe ct io n s Lo w -gra d e in fe ct io n

Healin g in periprosth etic in ection s is de n ed as m eetin g With im plan t-associated in ection s, low -viru len t, oth erw ise
th e ollow in g criteria: n on path ogen ic bacteria su ch as Staphylococcus epidermidis
take advan tage o th e act th at th e bodys de en ces again st
No h istory or clin ical sign s o in ection sym ptom s in ection are w eaken ed du e to a locally acqu ired gran u locyte
Norm alization o C-reactive protein (CRP) < 10 m g/ L de ect in th e im m ediate vicin ity o th e im plan t. Th ese bac-
an d/ or eryth rocyte sedim en tation rate (ESR) < 20 m m / h teria can also establish th em selves as a bio lm on th e su r ace
No radiological sign s o in ection > 24 m on th s a ter th e o th e im plan t. Th is leads to an exogen ou s in ection w ith
rst in ected revision delayed m an i estation th at is restricted to th e im m ediate
vicin ity o th e oreign body.
Healin g is con sidered likely to occu r in relapse- ree patien ts
betw een 12 an d 24 m on th s. A persisten t in ection (or re- Min im u m in h ib it o r y co n ce n t ra t io n (MIC) a n d
lapse) occu rs w ith recru descen t in ection w ith th e sam e p h a rm a co d yn a m ics
m icroorgan ism s an d is n ot tim e-depen den t. A n ew in ection Th e m in im u m in h ibitory con cen tration (MIC) correspon ds
is de n ed as occu rren ce o an in ection w ith di eren t m i- to th e an tibiotic level at w h ich bacteria are in h ibited. Th e
croorgan ism s. relation sh ip betw een th e an tibiotic level an d th e MIC can
be u sed to estim ate h ow lon g th e an tibiotic level w ill rem ain
In fe ct io n cla s s ifica t io n above th e MIC betw een dosages. In th e case o all -lactam s
(pen icillin s an d ceph alosporin s), it is ben e cial to m ain tain
In ection classif cation based on time o initial mani estation a ter surgery th e an tibiotic level above th e MIC at th e ocu s o in ection
Osteosynthesis Early infection 2 wk or as lon g as possible. For severe in ection s (eg, en docar-
Delayed infection 310 wk ditis or periprosth etic in ection ), it is th ere ore advisable to
Late infection 10 wk determ in e th e MIC.
Joint replacement Early infection 3 mo
Delayed infection 324 mo MRSA
Late infection 24 mo Meth icillin -resistan t Staphylococcus aureus. Alth ou gh it is n o
In ection classif cation based on pathogenesis lon ger cu rren tly u sed in clin ical application s, m eth icillin is
Exogenous Inoculation from outside (perioperative) usually manifesting within an in dicator o resistan ce to lu cloxacillin , am oxicillin /
the first 2 years clavu lan ic acid, an d ceph alosporin s.
Hematogenous Inoculation via the bloodstream at any time

MRSE
In o cu lu m e ffe ct Meth icillin -resistan t Staphylococcus epidermidis (see MRSA).
Bacterial den sity is h igh er in abscesses th an in stan dardized
resistan ce testin g (> 10 6 CFU/ m L vs 10 5 CFU/ m L). Th e
in ocu lu m e ect re ers to th e decreasin g e cacy o certain
an tibiotics, eg, -lactam an tibiotics, w ith in creasin g m icro-
bial cou n ts, w h ich m u st be taken in to accou n t du rin g
th erapy. Th is is th e reason w h y w ith im plan t-associated
in ection s th e ocu s o in ection m u st be eradicated u sin g
care u l debridem en t prior to an tibiotic treatm en t.

470 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Glossary
Op e n fra ct u re
Gu stilo-An derson open ractu re classi cation
Grade Criteria
1 Clean wound, wound < 1 cm in length, simple fracture
2 Wound > 1 cm in length without extensive soft-tissue damage
3a Open fracture with adequate periosteal coverage of the fractured bone despite
an extended soft-tissue damage, caused by high-energy trauma
3b Open fracture with extensive soft-tissue loss, periosteal stripping, and bone
exposure
3c Open fracture associated with an arterial injury requiring repair
Os t e o m ye lit is
In ection o th e bon e an d bon e m arrow . Osteom yelitis is
classi ed as acu te or ch ron ic, depen din g on progression . An
etiological distin ction is draw n betw een exogen ou s an d h e-
m atogen ou s osteom yelitis. Exogen ou s in ection s m ay spread
rom a w ou n d, eg, a pressu re u lcer, or pen etrate th e bon e
via an open ractu re, a su rgical access site, or a postoperative
w ou n d w ith im paired h ealin g.
PCR
Th e polym erase ch ain reaction (PCR) is a m eth od u sed to
iden ti y bacterial DNA. With PCR bacteria can be detected
even i th ey h ave already been killed. Th is m ean s th at eu -
bacterial PCR can occasion ally iden ti y bacteria th at can n ot
be cu ltivated. It is con siderably m ore di cu lt to in terpret
th e PCR w ith polym icrobial n din gs. In addition , m olecu lar
biological an alysis on ly en ables th e iden ti cation o isolated
resistan ces (eg, MRSA or ri am pin resistan ce). Presen tly th e
m eth od is con stan tly u n dergoin g u rth er developm en t.
Pro o f o f in fe ct io n
Meetin g at least on e o th e ollow in g criteria satis es proo
o in ection :
Abscess w ith pu s disch arge, possibly ollow in g in cision
Presen ce o a stu la
Microbiological iden ti cation o th e sam e path ogen in
at least tw o sam ples (tissu e sam ples, son ication o
oreign bodies)
Histological testin g o periprosth etic tissu e/ im plan t
bed: total o m ore th an 2025 gran u locytes in 10 elds
o view at 400x m agn i cation
Se n s it ivit y
Likelih ood o a test detectin g a tru e positive valu e w ith a
positive test resu lt.
P (positive resu lt | tru e positive) =
Nu m ber o tru e positives
Nu m ber o tru e positives + n u m ber o alse n egatives
Se p s is
Acu te system ic in f am m atory respon se th at orm s an organ -
ism s reaction to an in ection . O ten li e-th reaten in g, h igh
risk o h em atogen ou s spread to en doprosth etic im plan ts,
especially w ith S aureus.
Se q u e s t ru m
In ected, n ecrotic bon e ragm en t th at n o lon ger h as a stable
con n ection to vital bon e.
Sin gle -s h o t
Sin gle an tibiotic dosage adm in istered as a proph ylaxis prior
to su rgical procedu res.
SIRS
System ic in f am m atory respon se syn drom e. Th is is re erred
to as sepsis i it is cau sed by an in ection . In addition to a
detected or presu m ed ocu s o in ection , at least tw o o th e
ollowin g criteria m u st be m et to con rm a diagn osis o sepsis:
Body tem peratu re > 38C or < 36C
Heart rate > 90 beats/ m in (tach ycardia)
Tach ypn oea: breath in g rate > 20 breath s/ m in or
h yperven tilation w ith pCO 2 < 32 m m Hg
Leu kocytosis (> 12,000 cells/ L) or leu kopen ia
(< 4,000 cells/ L) or le t sh i t (ie, > 10% im m atu re
leu kocytes in th e di eren tial blood cou n t)
Sm a ll-co lo n y va ria n t s (SCV)
Bacterial popu lation s (u su ally Staphylococcus aureus) th at
orm sm all colon ies du e to th eir slow grow th . Th ese occu r
du rin g prolon ged exposu re to an tibiotics an d cau se ch ron ic
an d recu rren t in ection s. Th ey are h igh ly resistan t to an ti-
biotics n ot sh ow in g a reliable in vitro/ in vivo correlation .
471
 Glossary

So n ica t io n
Procedu re or detectin g bacterial colon ies xed in th e bio lm
on explan ts. Th e bio lm is rem oved rom oreign bodies
u sin g u ltrasou n d. Th e bacteria are released an d can th en be
cu ltivated in th e appropriate m edia.

Sp e cificit y
Likelih ood o a test to detect a tru e n egative valu e w ith a
n egative test resu lt.

P (n egative resu lt | tru e n egative) =

Nu m ber o tru e n egatives
Nu m ber o tru e n egatives + n u m ber o alse positives

Sp o n d ylit is
Bacterial or abacterial in f am m ation o on e or m ore vertebrae.

Sp o n d ylo d is cit is
Bacterial or abacterial in f am m ation o on e or m ore in terver-
tebral disc spaces an d th e adjacen t vertebrae. It is virtu ally
alw ays attribu table to spon dylitis in adu lts.

Th e ra p y w it h a n t ib io t ics
We di eren tiate betw een proph ylactic (preven tive) pre-
em ptive, em piric an d targeted th erapy.

472 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Inde x

Inde x

Page num be rs in ita lics re fe r to gure s
and/ or table s
An tibiotic ailu re
dru g-dru g in teraction s in , 67
in toleran ce o agen ts in , 67
m edial reason s or, 66 67
m icrobiological reason s or, 6 6 , 6 6
in open ractu res, 125 126 , 126
ph arm acokin etics o , in bon e, 65
preem ptive, 6 4
stew ardsh ip o , 63
su ppressive th erapy w ith , 65

A n on com plian ce in , 67
redu ced absorption o orally adm in istered
targeted th erapy w ith , 6 4
treatm en t stu dies, 65
Abscesses, 11 , 253 agen ts in , 67 , 68 6 9 An tibodies, 22 24 , 23 , 111
Absorbable su tu res, 51 An tibiotic proph ylaxis, 55 , 55 56 An tich olin ergics, 6 8
Absorption , redu ced, o orally adm in istered biopsy an d, 106 An tiseptic agen ts, 7 7 78
agen ts, 67 , 6 8 69 de n ed, 64 An tiseptic skin preparation , 48 , 48 49
Acinetobacter baumannii, 30 An tibiotic resistan ce, 32 , 32 33 Argin ase, 7
Actinomyces israelii, 192 an tibiotic m isu se an d, 63 Arth ro brosis, in septic arth ritis, 232 , 232
Actinomyces naeslundii, 192 em piric th erapy an d, 72 Arth rograph y, 95
Aggregatibacter actinomycetemcomitans, 215 in en terobacteria, 39 Arth roplasty. See Periprosth etic join t in ection
Agin g, w ou n d h ealin g an d, 26 6 as reason or treatm en t ailu re, 6 6 , 6 6 (PJI)
Albu m in , 10 screen in g or, 72 Arth roscopic lavage, in septic arth ritis, 229
Alcoh ol in sm all colon y varian ts, 66 Arth roscopy, in septic arth ritis, 219 , 220 , 220
in h an d w ash in g, 50 An tibiotics/ an tim icrobials Aspergillus, 42
or skin preparation , 48 , 49 in erysipelas, 251 , 251 Aspiration . See Join t aspiration
Alcoh ol con su m ption , 46, 19 0 , 19 0 in ter eren ce o , in biopsy, 106 Aten olol, 68
Algin ates, in w ou n d dressin g, 26 8 local delivery o Atrau m atic su rgical tech n iqu e, 51 52
Allogra t, in in ected n on u n ion , 17 7 , 18 4 , 185 an tiseptics in , 77 78 Attire, su rgical, 50 , 50
Allopu rin ol, 68 basics o , 77
Am in oglycosides bioglass in , 8 6
ree DNA an d, 6 6 calciu m su l ate in , 85 , 85 B
in open ractu res, 125 carriers in , 79 , 80 , 8 0 8 6 Bacillus anthracis, 38
Am oxicillin ch lorh exidin e in , 78 Bacillus cereus, 38 , 38
bioavailability, 71 coated im plan ts in , 8 6 Bacillus spp, 38
com pou n ds in f u en cin g absorption an d collagen in , 85 Bacillus subtilus, 38
con cen tration o , 6 8 gen tam icin in , 79 , 8 0 , 8 0 82 , 82 , 8 6 Bacterial resistan ce, 32 , 32 33
dose, 70 , 71 Masqu elet tech n iqu e in , 8 4 , 8 4 85 Bacteroides, 256
in septic arth ritis, 221 , 222 octen idin e dih ydroch loride, 78 BAG-S53 P4 , 86
spectru m , 70 , 71 in open ractu res, 127 , 127 , 157 Bio lm
Am picillin polyh exan ide in , 7 7 as adaptation , 5
com pou n ds in f u en cin g absorption an d polym eth ylm eth acrylate in , 80 , 8 0 85 , an tibiotic resistan ce an d, 33
con cen tration o , 6 8 82 8 4 de n ed, 5
dose, 70 povidon e-iodin e in , 78 den tal, 5
in open ractu res, 126 ri am pin in , 79 oreign bodies an d, 5
spectru m , 70 silver in , 8 6 orm ation o , 5 8 , 6 , 8
Am pu tation , in periprosth etic join t tobram ycin in , 79 in ractu res, 14 0
in ection , 202 , 2 05 van com ycin in , 79 , 83 , 83 84 h istory o term , 5
An aerobic bacteria, 4 0 42 , 41 in n ecrotizin g so t-tissu e in ection s, 260 , im plan t-associated (See also In ection ,
An aph ylatoxin s, 21 22 261 im plan t-associated)
An giograph y, in in ected n on u n ion , 171 in periprosth etic join t in ection , 4 05 basics o , 3 , 4
An idu la u n gin , in septic arth ritis, 222 in septic arth ritis, 221 , 222 , 230 iden ti cation o , 3 , 4
An im al bites, 256 257 in septic bu rsitis, 254 in teraction w ith im plan t an d, 9 10
An kle arth roplasty, im plan t rem oval in acu tely in skin an d so t-tissu e in ection s, 249 in m icroscopy, 3 , 4 , 6
in ected, 4 0 9 413 , 4 09 413 in spon dylodiscitis, 237 ri am pin in , 72
An kle-brach ial ref ex, 26 6 system ic in in ection path ology, 5
An tacids, 6 8 ch oice o , 6 4 m atrix (See Extracellu lar polym eric
An terior iliac crest, as h arvestin g site, 175 de n ition o u se o , 6 4 su bstan ce (EPS))
An tiarrh yth m ic dru gs, 6 8 em piric th erapy w ith , 6 4 , 71 72 on so t tissu e, 5
im portan t, 70 , 71 , 71 72 , 73 as viru len ce actor, 30
m isu se o , 63 zon es in , 5 , 6

473
 Inde x

Bioglass, 8 6 Calorim etry, 110 , 110 Clin dam ycin

Biological dressin gs, 270 Campylobacter, 216 in an tibiotic proph ylaxis, 55
Biopsy Candida albicans, 30 , 227 bioavailability, 71
an tibiotic in ter eren ce in , 106 Candida spp., 42 , 215 , 215 , 222 com pou n ds in f u en cin g absorption an d
an tibodies in , 111 Capnocytophaga canimorsus, 215 con cen tration o , 6 9
calorim etry w ith , 110 Carbapen em , in n ecrotizin g so t-tissu e dose, 71
cu ltu rin g, 105 , 106 107 in ection s, 261 in n ecrotizin g so t-tissu e in ection s, 261
in diagn osis, 92 , 105 114 Carbapen em ase-produ cin g bacteria, 72 spectru m , 71
electrospray ion ization m ass spectrom etry Carbu n cles, 252 Clin ical presen tation , 31
in , 108 Cardiobacterium hominis, 215 Clostridia, 41
resh - rozen section s in , 109 Care bu n dle, 57 Clostridium botulinum, 41
h istology in , 109 Caspo u n gin , in septic arth ritis, 222 Clostridium di cile, 41
h om ogen ization in , 105 , 105 Cation s, 6 8 Clostridium per ringens, 41
IBIS T50 00 in , 108 Ce azolin Clostridium septicum, 41
m icrobiological exam in ation o , 106 107 in an tibiotic proph ylaxis, 55 , 55 Clostridium tetani, 41
polym erase ch ain reaction test w ith , 107 dose, 70 Closu re
10 8 in open ractu res, 125 in atrau m atic tech n iqu e, 51 , 52
son ication w ith , 111 113 , 111 114 spectru m , 70 in in ected n on u n ion , 181 , 182 , 18 6
tran sport o , 106 Ce epim e in open ractu res, 130 , 130 131
vortexin g in , 113 dose, 70 Coagu lase-n egative staph ylococci (CoNS), 35
Biosu rgery, in skin an d so t-tissu e in septic arth ritis, 222 36
in ection s, 250 spectru m , 70 Coagu lase test, 31 , 31
Bite w ou n ds, 256 257 Ce tazidim e Coated im plan ts
BJI In oplex, 111 dose, 70 in local delivery o an tibiotics, 86
Blood m arkers, 93 94 , 94 , 195 in septic arth ritis, 222 in periprosth etic join t in ection , 206 , 2 07
Blood tests spectru m , 70 Collagen , as an tibiotic carrier, 85
in diagn osis, 92 , 92 94 , 94 Ce triaxon e Com partm en t syn drom e, 123 , 124
in ractu re in ection , 152 dose, 70 Com plem en t protein s, 10 , 21
in ractu re in ection s, 152 in n ecrotizin g so t-tissu e in ection s, 261 Com pu ted tom ograph y (CT)
in periprosth etic join t in ection , 194 195 , in septic arth ritis, 221 , 222 in diagn osis, 100 , 100
195 spectru m , 70 positron -em ission , 103
in septic arth ritis, 216 , 228 Ce u roxim e in ractu re in ection , 153 , 153
in skin an d so t-tissu e in ection s, 247 , 259 in an tibiotic proph ylaxis, 55 , 55 in in ected n on u n ion , 171
in spon dylodiscitis, 237 in septic arth ritis, 221 CoNS. See Coagu lase-n egative staph ylococci
in w ou n ds, 26 6 Cell-based dressin gs, 270 (CoNS)
BMP. See Bon e m orph ogen ic protein s (BMP) Cellu litis, 252 , 252 , 259 Con tam in ation , o operatin g room , 53
Bon e cem en t, gen tam icin in , 33 . See also Cem en t. See Bon e cem en t; Con traceptives, 68
Polym eth ylm eth acrylate (PMMA) Polym eth ylm eth acrylate (PMMA) Corynebacterium spp., h an d scru bbin g an d, 50
Bon e gra t Ceph alosporin s Costerton , William , 5
au togen ou s, in in ected n on u n ion , 175 in open ractu res, 126 Cotrim oxazole
17 7 , 176 , 177 oral orm u lation o , 72 bioavailability, 71
vascu larized, in in ected n on u n ion , 183 , Ch em oth erapy, 26 6 com pou n ds in f u en cin g absorption an d
18 4 Ch ildren . See Pediatric patien ts con cen tration o , 6 8 , 6 9
Bon e m orph ogen ic protein s (BMP), in in ected Chlamydia, 216 dose, 71
n on u n ion , 177 178 Ch lorh exidin e, 47 , 48 , 49 , 50 , 78 spectru m , 71
Bon e resorption , 11 Ch loroqu in e, 6 8 C-reactive protein (CRP), 22 , 92 , 152 , 194 , 195
Bon e scan s. See Scin tigraph y Ch ron ic in ection s, 11 CRP. See C-reactive protein (CRP)
Brodies abscess, 98 Ch ron ic ven ou s in su cien cy, 266 Crystal an alysis, 95 , 216 , 217 , 217
Brucella spp., 215 Ciern y-Mader classi cation , 143 146 , 143 146 CT. See Com pu ted tom ograph y (CT)
Bu n dle, care, 57 Cim etidin e, 6 9 Cu tan eou s abscess, 253
Bu rsitis, septic, 253 255 Ciprof oxacin Cyclosporin e, 6 8 , 6 9
Bu su l an , 6 9 bioavailability, 71 Cytoch rom e P450 in h ibitors, 6 8
com pou n ds in f u en cin g absorption an d Cytokin es, 10 , 21 , 26
con cen tration o , 6 8
C dose, 71
C1 , 24 in septic arth ritis, 222 D
C3 b, 21 spectru m , 71 Daptom ycin
C5 a, 21 22 Ciprof oxacin -resistan t en terobacterial dose, 70
Calciu m su l ate, 85 , 85 in ection , 39 as local an tibiotic, 8 0
Clavu lan ic acid, 68 in n ecrotizin g so t-tissu e in ection s, 261
Clean sin g, o skin , 47 in septic arth ritis, 222
spectru m , 70

474 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Inde x

Debridem en t
in ractu re in ection , 29 0
Digoxin , 68
Distraction osteogen esis. See Ilizarov m eth od F
o h u m eru s in ection a ter rotator cu Do etilid, 69 Fem oral ractu re
repair, 295 Doxycyclin e acu tely in ected
in in ected n on u n ion , 172 173 , 173 , 301 , bioavailability, 71 w ith h ip screw, 297 307 , 297 308
301 , 363 , 36 4 com pou n ds in f u en cin g absorption an d w ith n ail, 313 316 , 313 317
o open ractu res, 128 , 128 129 con cen tration o , 6 8 ch ron ically in ected, 331 335 , 331 336
in periprosth etic join t in ection , 197 19 9 , dose, 71 Fem u r
341 , 393 , 393 , 403 , 410 , 410 , 417 418 , 418 , 421 in septic arth ritis, 222 acu te osteom yelitis in , 351 355 , 351 355
in septic arth ritis, 230 , 230 spectru m , 71 as h arvestin g site, 175
in su rgical-site in ection , 295 , 310 , 310 Drain , 52 osteom yelitis in , 453 460 , 453 461 ,
o tibial n ail, 28 4 Drapin g, in preven tion , 49 , 49 463 467 , 463 46 8
o w ou n ds, 267 Dressin gs, or open w ou n ds, 26 8 , 26 8 , 270 septic arth ritis in , 453 46 0 , 453 461
Decortication , in in ected n on u n ion , 175 Dru g-dru g in teraction s, 67 Fibrin lam en ts, 3 , 4 , 6
Delayed closu re, 52 , 131 Du ration o su rgery, 52 Fibrin ogen , 10
Delayed u n ion , in tibia, w ith broken Fibroblast grow th actor, 267 , 26 8
im plan ts, 297 307 , 297 308 . See also Fibron ectin , 10
Fractu res, in ected n on u n ion E Fibroplasia, in w ou n d h ealin g, 265
Den dritic cells, 24 Eikenella corrodens, 215 Fibu la, as ree vascu larized bon e gra t
Den tal bio lm s, 5 Elbow arth roplasty, im plan t rem oval in acu tely sou rce, 183
Den tal procedu res, 192 in ected, 415 , 415 421 , 418 , 419 Film s, in w ou n d dressin g, 26 8
Diabetic n eu ropath ic u lcers, 267 . See also Electrospray ion ization m ass Fin egoldia, 42
Wou n ds spectrom etry, 108 Finegoldia magna, 42
Diabetic patien ts, 45 , 46 , 265 , 266 Em piric th erapy, 6 4 , 71 72 , 221 , 222 , 249 Fistu lograph y, in in ected n on u n ion , 171
Diagn osis En docarditis, 192 , 221 Fixation . See also Ilizarov m eth od
algorith m , 91 En dogen ou s in ection , exogen ou s vs., 32 in in ected n on u n ion , 173 , 174 , 304 , 304
arth rograph y in , 95 En terobacteria, 39 , 39 o open ractu res, 132 , 132 133 , 133 , 140
basics, 91 Enterobacter spp., 66 in in ection classi cation , 147 150 ,
blood m arkers in , 93 94 , 94 En terococci, 37 147 150
blood tests in , 92 , 92 94 , 94 Enterococcus aecalis, 30 , 37 in tibial in tram edu llary n ail
com pu ted tom ograph y in , 100 , 100 Enterococcus aecium, 30 , 37 in ection , 285 , 285
C-reactive protein in , 92 Enterococcus spp., in septic arth ritis, 222 Flaps, 270
cu ltu re-n egative in ection in , 9 6 Epiderm al grow th actor, 267 Flash sterilization , 53
o cu tan eou s abscess, 253 Epith elialization , in w ou n d h ealin g, 265 FLOW. See Flu id lavage o open wou n ds (FLOW)
o erysipelas, 251 , 251 EPS. See Extracellu lar polym eric su bstan ce (EPS) Flu cloxacillin
eryth rocyte sedim en tation rate in , 92 Ertapen em dose, 70
o ractu re in ection s, 151 154 , 151 155 dose, 70 in septic arth ritis, 222
im m u n ology in , 93 spectru m , 70 spectru m , 70
in terleu kin - 6 in , 93 Erysipelas, 251 , 251 Flu con azole, in septic arth ritis, 222
in traoperative sam ples in , 92 Eryth rocyte sedim en tation rate (ESR), 92 , Flu id lavage o open w ou n ds (FLOW), 78
join t pu n ctu re in , 92 , 94 9 6 , 95 194 , 195 Flu oroqu in olon es
leu kocyte cou n t in , 92 Eryth rom ycin , clin dam ycin an d, 69 in acid en viron m en t, 6 6
leu kocyte esterase test, 95 , 95 Escherichia coli, 30 in n ecrotizin g so t-tissu e in ection s, 261
m agn etic reson an ce im agin g in , 100 , 101 , gastroin testin al procedu res an d, 192 193 Foam s, in w ou n d dressin g, 26 8
102 h an d scru bbin g an d, 50 Foreign bodies, 9
in m icrobiology, 33 pro le, 39 Fou n der species, 5
n u clear m edicin e in , 103 104 , 104 ESR. See Eryth rocyte sedim en tation rate (ESR) Diagn osis
o periprosth etic join t in ection , 192 19 6 , Exogen ou s in ection , en dogen ou s vs., 32 in ected n on u n ion in
193 19 6 Extern al xation . See also Ilizarov m eth od allogra t in , 17 7 , 18 4 , 185
procalciton in in , 93 in in ected n on u n ion , 173 , 174 an giograph y in , 171
radiology in , 92 , 97 10 4 , 9 8 104 in lim ited resou rce patien ts, 46 4 , 467 approach in , 172 , 173
scin tigraph y in , 10 4 , 10 4 lockin g com pression plate or, 467 , 467 au togen ou s bon e gra t in , 175 177 , 176 ,
o septic arth ritis, 216 , 216 217 , 217 o open ractu res, 133 , 150 , 150 177
o septic bu rsitis, 253 254 Extracellu lar polym eric su bstan ce (EPS) bon e actors in , 170
o skin an d so t-tissu e in ection s, 247 com position o , 5 bon e m orph ogen ic protein in , 17 7 178
248 , 258 , 258 259 -degradin g en zym es, 7 case stu dy, 297 307 , 297 308 , 361 ,
son ograph y in , 103 , 103 in den tal bio lm , 5 361 36 8 , 362 , 36 4 36 8 , 36 9 377 , 36 9 378
o spon dylodiscitis, 236 , 237 polym erized-N-acetylglu cosam in e in , 5 classi cation o , 16 8 , 16 8 16 9 , 170
tu m or n ecrosis actor in , 93 w ith S. aureus, 5 com plication s w ith , 18 6
X-ray in , 97 , 98 , 9 9 , 101 w ith S. epidermidis, 5 debridem en t o , 172 173 , 173 , 301 , 301 ,
Extrem ity, m an gled, 134 , 134 135 363 , 36 4 , 372 , 372

475
 Inde x
decortication in , 175
de n ed, 167
diaph yseal, 16 9
epiph yseal-m etaph yseal, 16 9
exploration o , 172 , 173
extern al xation in , 173 , 174
actors in developm en t o , 167 , 167
stu lograph y in , 171
ree vascu larized bon e tran s er in , 183 ,
18 4
u n ction al statu s assessm en t in , 172
Ilizarov m eth od in , 178 182 , 179 182
im agin g in , 171 172
in du ced m em bran e prin ciple an d, 178 ,
178
in tern al xation in , 174 , 304 , 304
in tram edu llary n ailin g in , 174
laboratory tests in , 170
n on viable, 16 8
open can cellou s bon e gra tin g in , 17 7 ,
177
osteoplastic m easu res in , 175 185 ,
176 182 , 18 4 , 185
ou tcom es in , 18 6 , 305 306 , 305 307
Papin eau tech n iqu e in , 17 7 , 177
patien t actors in , 170
pit alls w ith , 308
reim plan tation in , 30 4 , 30 4 , 30 8
scin tigraph y in , 171
skin de ect closu re in , 181 , 182 , 18 6
so t tissu e actors in , 170
stabilization o , 173 , 173 174
in tibia, 297 307 , 297 308 , 36 9 377 ,
36 9 378
treatm en t o , 172 18 6 , 173 , 176 182 ,
18 4 , 185
vascu larized bon e tran s er in , 183 , 18 4
viable, 16 8
X-ray in , 171
in ection a ter
in acetabu lu m , 14 0
acu te, 156 158 , 158
bio lm s in , 14 0
case stu dy, 289 291 , 28 9 291 , 297 307 ,
297 308 , 313 316 , 313 317 , 319 , 319 324 ,
323 , 325 328 , 325 329 , 331 335 , 331 336 ,
345 , 345 350 , 346 , 349
ch ron ic, 159 163 , 16 0 163 , 325 328 ,
325 329 , 331 335 , 331 336 , 345 , 345 350 ,
346 , 349
Ciern y-Mader classi cation o , 143 146 ,
143 146
classi cation o , 141 146 , 142 146
com pu ted tom ograph y in , 153 , 153
delayed presen tation o , 159 16 0 ,
16 0 161
diagn ostics o , 151 154 , 151 155
etiology o , 139 14 0
in extern al xation , 150 , 150
xation m eth od in , 147 150 , 147 150
in oot, 14 0
476
in h ealed ractu re, 162 , 162 163 , 163
w ith h ip screw, 297 307 , 297 30 8 G
h istopath ology o , 141 , 141 Galliu m - 57 , 10 4
im agin g stu dies or, 152 154 , 152 154 Gan gren e, 259
in ciden ce o , 139 140 Gas gan gren e, 259
in in tram edu llary n ailin g, 149 , 149 , 157 Gastroin testin al procedu res, 192 193
laboratory tests or, 152 Gen tam icin
late presen tation o , 16 0 163 , 162 , 163 in coated im plan ts, 8 6
in lateral m alleolu s, 289 291 , 28 9 291 in tracellu lar bacteria an d, 33
local an tibiotic delivery in , 157 as local an tibiotic, 79 , 80 , 80 82 , 82 , 8 6
m agn etic reson an ce im agin g in , 154 , 154 in open ractu res, 125
m icrobiological diagn osis in , 155 in polym eth ylm eth acrylate beads, 8 0 ,
in n on u n ion , 163 80 82 , 82
n u clear im agin g in , 154 , 154 Gloves, 50
path ogen esis o , 14 0 Glycosidases, 7
in pelvic rin g, 140 GM-CSF. See Gran u locyte-m acroph age colon y
in plate osteosyn th esis, 148 , 148 stim u latin g actor (GM-CSF)
positron -em ission tom ograph y in , 154 , Gold, 86
154 Gra ts. See Bon e gra t; Skin gra ts
treatm en t o , 156 163 , 158 , 16 0 163 Gram -n egative bacteria
X-ray in , 152 , 152 m u ltidru g-resistan t, 72
open pro le, 38 4 0 , 39 , 4 0
an tibiotic th erapy in in skin preparation , 48
local, 127 , 127 , 157 Gram -positive bacteria
system ic, 125 126 , 126 pro le, 34 38 , 34 38
an tiseptic u se in , 78 in skin preparation , 48
assessm en t o , 123 , 124 Gram -positive toxic sh ock syn drom e, 259
classi cation o , 125 Gram stain , in join t pu n ctu re, 95
com partm en t syn drom e in , 123 , 124 Gran u locyte-m acroph age colon y stim u latin g
debridem en t o , 128 , 128 129 actor (GM-CSF), 267
extern al xation o , 133 , 150 , 150 Grow th actors, in w ou n d m an agem en t, 267
xation o , 132 , 132 133 , 133 , 140
in in ection classi cation , 147 150 ,
147 150 H
in tram edu llary n ailin g in , 132 , 132 , 149 , HACEK grou p, 215
149 , 157 Haemophilus spp., 215 , 221
irrigation o , 128 , 128 129 Hair rem oval, 48
m an gled extrem ity in , 134 , 134 135 Han d h ygien e, 49 50
plate an d screw xation o , 133 , 133 , Harvestin g, o can cellou s au togra t, 175
147 , 147 148 , 148 HBO. See Hyperbaric oxygen (HBO)
risks o , 123 Healin g, o w ou n ds, 265
so t-tissu e coverage an d recon stru ction Heart valves, prosth etic, 56
in , 131 -h em olysin (Hla), 7
w ou n d closu re in Hip, periprosth etic join t in ection in , 2 04 ,
delayed, 131 205 , 337 339 , 337 344 , 379 382 , 379 382
prim ary, 130 , 130 Hip h em iarth roplasty, ch ron ically
Free vascu larized bon e tran s er, in in ected in ected, 337 339 , 337 344
n on u n ion , 183 , 18 4 Hip screw, in acu tely in ected em oral
Fresh - rozen section s, 109 ractu re, 297 307 , 297 308
Fu n gi Histam in e release, 21 22
pro le, 42 Histology, in biopsy, 109
in skin preparation , 48 History
Fu ru n cles, 252 in n ecrotizin g so t-tissu e in ection , 258 259
Fu sidic acid in periprosth etic join t in ection , 192 193
bioavailability, 71 in skin an d so t-tissu e in ection s, 247
com pou n ds in f u en cin g absorption an d Hla. See -h em olysin (Hla)
con cen tration o , 6 9 Horm on al con traceptives, 6 8
dose, 71 Hu m an bites, 256 257
in septic arth ritis, 222
spectru m , 71
Fusobacterium, 256
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Inde x

Hu m eru s
in ected n on u n ion o , 361 , 361 36 8 , 362 ,
36 4 36 8
in ection o , a ter rotator cu repair, 293 ,
293 29 6 , 294
osteom yelitis in proxim al, 435 4 41 ,
435 441
Hydroactive dressin gs, 268
Hydrocolloids, in w ou n d dressin g, 26 8
Hydrogels, in w ou n d dressin g, 26 8
Hyperbaric oxygen (HBO)
in open w ou n ds, 270
in skin an d so t-tissu e in ection s, 249 , 26 0
Hyperten sive u lcers, 267 . See also Wou n ds
I in periprosth etic tissu e, de n ed, 10 9
IBIS T50 00 , 108
Ica operon , 5 7
IgA. See Im m u n oglobu lin -A (IgA)
IgE. See Im m u n oglobu lin -E (IgE)
IgG. See Im m u n oglobu lin -G (IgG)
IgM. See Im m u n oglobu lin -M (IgM)
Iliac crest
as ree vascu larized bon e gra t sou rce, 183
as h arvestin g site, 175
Ilizarov m eth od, 178 182 , 179 182
Im agin g. See Radiology
Im ipen em
dose, 70
spectru m , 70
Im m u n ity
adaptive, 19 , 2 0 , 22 25 , 23 , 25
cellu lar, 19
com m u n ication in , 24
h u m oral, 19
im paired, 25 26
in f am m atory ph ase in , 10 11
in n ate, 19 , 2 0 , 21 22 , 24 , 25
m em ory in , 24
path ogen s in im pairm en t o , 26
role o , 19
as tw o system s, 19 , 2 0
Im m u n ode cien cies, 25 26 , 45 , 167 , 26 6
Im m u n oglobu lin -A (IgA), 23
Im m u n oglobu lin -E (IgE), 23
Im m u n oglobu lin -G (IgG), 22 23 , 23
Im m u n oglobu lin -M (IgM), 23
Im m u n ology, in diagn osis, 93
Im paired im m u n ity, 25 26
Im plan t-associated bio lm . See Bio lm ;
In ection , im plan t-associated
Im plan t ailu re, tibial delayed u n ion in , 297
307 , 297 308
In cision s
in atrau m atic tech n iqu e, 51
open , 54
In diu m - 111 , 104
In dom eth acin , cotrim oxazole an d, 6 9
In du ced m em bran e prin ciple, 178 , 178
In ected n on u n ion . See Fractu res, in ected
n on u n ion in J
In ection , im plan t-associated. See also Bio lm , Join t arth roplasty. See Periprosth etic join t
im plan t-associated in ection (PJI)
ch ron ic, 11 Join t aspiration , in septic arth ritis, 219 , 229
clin ical presen tation o , 31 Join t pu n ctu re
en dogen ou s vs. exogen ou s, 32 in diagn osis, 92 , 94 96 , 95
im m u n e respon se in , 10 procedu re, 94
path ogen esis o , 10 12 , 13 Join t replacem en t, 3
rein ection , 11
rou tes o , 9
species in , requ en cy o , 29 K
In ection , su rgical-site. See Su rgical-site Ketocon azole, 6 8
in ection s (SSIs) Kingella kingae, 215
In ection preven tion . See Preven tion Klebsiella oxytoca, 39
In f am m ation
Klebsiella pneumoniae, 39 , 193
Kn ee
in w ou n d h ealin g, 265 im plan t rem oval in , 391 39 8 , 391 399
In f am m atory m arkers, 92 periprosth etic join t in ection in , 204 , 2 05 ,
In f am m atory ph ase, 10 11 383 38 9 , 383 390 , 391 39 8 , 391 39 9
In stru m en t sterilization , 53 Kn ee arth rodesis, in periprosth etic join t
In teraction s, dru g-dru g, 67 in ection , 2 02
In terleu kin - 1 (IL- 1 ), 10 Kn ee prosth esis, in periprosth etic join t
In terleu kin - 1 (IL- 1 ), 96 in ection , 2 02
In terleu kin - 6 (IL- 6 ), 10 , 22 , 93 , 96 , 195
In tern al xation , in in ected n on u n ion , 174 ,
30 4 , 30 4 L
In tracellu lar li estyle, 11 , 12 , 33 , 6 6
Laboratory tests
In tram edu llary n ail
in diagn osis, 92 , 92 94 , 94
case stu dy, 283 28 6 , 283 287 , 313 316 ,
in ractu re in ection s, 152
313 317
in periprosth etic join t in ection , 194 195 ,
in in ected n on u n ion , 174
195
in open ractu res, 132 , 132 , 149 , 149 , 157
in septic arth ritis, 216 , 228
tibial, acu tely in ected, 283 286 , 283 287
in skin an d so t-tissu e in ection s, 247 , 259
In traoperative sam ples
in spon dylodiscitis, 237
an tibiotic in ter eren ce in , 106
in w ou n ds, 266
an tibodies in , 111
Lam in ar airf ow, 53
calorim etry w ith , 110 , 110
Lan th an u m , 6 8
cu ltu rin g, 105 , 10 6 107 , 107
Lateral m alleolar ractu re, acu tely
in diagn osis, 92 , 105 , 105 114 , 107 ,
in ected, 28 9 291 , 289 291
110 113
LCP. See Lockin g com pression plate (LCP)
electrospray ion ization m ass spectrom etry
Leu kocyte cou n t, 92 , 194 , 195 , 217 , 217
in , 108
Leu kocyte esterase test, 95 , 95 , 195
resh - rozen section s in , 109
Levof oxacin
h istology in , 10 9
bioavailability, 71
h om ogen ization in , 105 , 105
com pou n ds in f u en cin g absorption an d
IBIS T500 0 in , 10 8
con cen tration o , 6 8
m icrobiological exam in ation o , 106 107 ,
dose, 71
107
in septic arth ritis, 222
polym erase ch ain reaction test w ith , 107
spectru m , 71
10 8
Lim ited resou rces, in ection treatm en t
son ication w ith , 111 113 , 111 114
w ith , 463 467 , 463 46 8
tran sport o , 10 6
Lin ezolid
vortexin g in , 113
bioavailability, 71
Iodin e, 48 , 49 , 50 , 78
com pou n ds in f u en cin g absorption an d
Irrigation
con cen tration o , 6 9
o open ractu res, 128 , 128 129
dose, 71
in periprosth etic join t in ection , 197 19 9
in n ecrotizin g so t-tissu e in ection s, 261
in septic arth ritis, 218 , 230
spectru m , 71
o w ou n ds, 267
Lipoderm atosclerosis, 248
Isch em ic u lcers, 267 . See also Wou n ds

477
 Inde x
Lipopolysacch aride (LPS), 22
Lipoteich oic acid (LTA), 22
Lister, Joseph , 48
Lockin g com pression plate (LCP), as extern al
xation , 467 , 467
LPS. See Lipopolysacch aride (LPS)
LTA. See Lipoteich oic acid (LTA)
M dose, 71
Macroph ages, 21
Maggots, in skin an d so t-tissu e
in ection s, 250
Magn etic reson an ce im agin g (MRI)
in diagn osis, 10 0 , 101 , 102
in ractu re in ection , 154 , 154
Malign an t u lcers, 267 . See also Wou n ds
Maln u trition , 45 , 26 6 , 276
Man gled extrem ity, 134 , 134 135
Man gled Extrem ity Severity Score
(MESS), 135
Masqu elet tech n iqu e, 8 4 , 8 4 85
Mass spectrom etry, 108
Mast cells, 21 22
Matrix. See Extracellu lar polym eric su bstan ce
(EPS)
Matu ration , in w ou n d h ealin g, 265
McPh erson classi cation , 191
Medial em oral con dyle, as ree vascu larized
bon e gra t sou rce, 183
Medical h istory. See History
Meropen em
dose, 70
in ractu re in ection , 157
in septic arth ritis, 222
spectru m , 70
MESS. See Man gled Extrem ity Severity Score
(MESS)
Meth icillin -resistan t S. aureus (MRSA)
in an tibtiotic proph ylaxis, 55
in erysipelas, 251
lim ited resou rces treatm en t o , 463 467 ,
463 468
in n asal decolon ization , 47
in open ractu res, 126
polyh exan ide or, 7 7
screen in g or, 72
in septic arth ritis, 213 , 221 , 222
in skin an d so t-tissu e in ection s, 249
Meth otrexate, 68
Meth oxyf u ran e, 6 8
Metron idazole
bioavailability, 71
com pou n ds in f u en cin g absorption an d
con cen tration o , 6 9
dose, 71
in n ecrotizin g so t-tissu e in ection s, 261
spectru m , 71
Microbial su r ace com pon en ts recogn izin g
adh esive m atrix m olecu les (MSCRAMMs), 5 , 9
Microcolon ies, 5 , 11
478
MicroDTTect system , 2 06 Neisseria, 256
Microorgan ism pro les, 34 41 , 34 42 Neisseria gonorrhoeae, 215
Microscopy, im plan t-associated bio lm in , 3 , NETosis, 21
4, 6 Nicotin e replacem en t th erapy, 26 6
Migration , in w ou n d h ealin g, 265 NOD2 / CARD15 , 22
Min ocyclin e NOD-like receptors, 22
bioavailability, 71 Non com plian ce, an tibiotic ailu re an d, 67
com pou n ds in f u en cin g absorption an d Non u n ion in ection . See Fractu res, in ected
con cen tration o , 6 8 n on u n ion in
Non -Un ion Scorin g System (NUSS), 16 9 , 170
spectru m , 71 NPWT. See Negative-pressu re w ou n d th erapy
Modu lin s, 7 (NPWT)
Mon ocyte ch em oattractan t protein NSTI. See Necrotizin g so t-tissu e in ection s (NSTI)
(MCP), 195 Nu clear m edicin e
Moxarella, 256 in diagn osis, 103 10 4 , 10 4
Moxif oxacin in ractu re in ection , 154 , 154
bioavailability, 71 in in ected n on u n ion , 171
dose, 71 in periprosth etic join t in ection , 19 6
in n ecrotizin g so t-tissu e in ection s, 261 Nu cleases, 7
spectru m , 71 NUSS. See Non -Un ion Scorin g System (NUSS)
MPC. See Mon ocyte ch em oattractan t protein
(MCP)
MRI. See Magn etic reson an ce im agin g (MRI) O
MSCRAMMs, 5 Obese patien ts, 45 , 46 , 167 , 248
Mycobacteria, 42 OCT. See Octen idin e dih ydroch loride (OCT)
Mycobacterium leprae, 42 Octen idin e dih ydroch loride (OCT), 78
Mycobacterium tuberculosis, 42 Open can cellou s bon e gra tin g, 17 7 , 177
Mycoph en olate, 6 8 Open ractu res. See Fractu res, open
Mycoplasma hominis, 215 , 215 Open in cision , 54
Open w ou n ds. See Wou n ds, open
N Operatin g room con tam in ation , 53
Opiu m derivatives, 6 8
Na cillin Opson ization , 21
dose, 70 Orally adm in istered agen ts
in n ecrotizin g so t-tissu e in ection s, 261 dru gs n ot recom m en ded or, 72
spectru m , 70 redu ced absorption o , an tibiotic ailu re
Nail. See In tram edu llary n ail an d, 67 , 68 69
Nasal decolon ization , 47 Osm iu m tetroxide, 3 , 4
Necrotizin g so t-tissu e in ection s (NSTI), 257 Osteoblasts, in ection o , 33
26 0 , 257 260 Osteom yelitis. See also Fractu res; Periprosth etic
Needle aspiration . See Join t aspiration join t in ection (PJI)
Negative-pressu re w ou n d th erapy (NPWT) bio lm in , 9 12
in acu te trau m a, 274 275 case stu dy, 351 355 , 351 355 , 357 36 0 ,
an xiety in , 276 357 36 0 , 423 428 , 424 427 , 429 433 ,
com plication s o , 275 276 430 432 , 435 4 41 , 435 441 , 443 445 ,
con train dication s or, 274 , 274 443 451 , 447 451 , 453 46 0 , 453 461
cost-e ectiven ess o , 276 cau sative organ ism s in , 426
evalu ation o treatm en t in , 275 in com pu ted tom ograph y, 100 , 100
in dication s or, 274 , 274 etiology o , 426
in ection rom , 275 in em u r, 351 355 , 351 355 , 453 46 0 ,
m aln u trition an d, 276 453 461 , 463 467 , 463 46 8
m ech an ism o action , 273 in ractu re in ection classi cation , 143
n eu ropeptides in , 273 146 , 143 146
in open w ou n ds, 272 276 , 274 join t in ection s vs., 65
pain w ith , 275 lim ited resou rces treatm en t o , 463 467 ,
in pediatric patien ts, 275 463 468
qu ality o li e in , 276 in m agn etic reson an ce im agin g, 10 0 , 101
secon dary e ects o , 273 path ogen esis o , 10 11
in skin an d so t-tissu e in ection s, 250 , 260 in pediatric patien ts, 423 428 , 424 427 ,
skin dam age in , 275 429 433 , 430 432 , 435 4 41 , 435 4 41 ,
trau m a rom , 275 443 445 , 443 451 , 4 47 451 , 453 46 0 ,
453 461
Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns
Inde x
ph arm acokin etics an d, 65
polym eth ylm eth acrylate beads in , 80 , 85
procalciton in in , 93
in scin tigraph y, 104 , 104
socioecon om ic backgrou n d an d, 423
in son ograph y, 103
in tibia, 357 36 0 , 357 36 0 , 429 433 ,
430 432
tu m or n ecrosis actor in , 93
in X-ray, 97 , 98
Oxicillin , in n ecrotizin g so t-tissu e
in ection s, 261
Oxygen ation , tissu e, 51
P n on su rgical treatm en t o , 197
PAMPs. See Path ogen -associated m olecu lar
pattern s (PAMPs)
Papin eau tech n iqu e, 17 7 , 177
Pasteu r, Lou is, 48
Pasteurella, 256
Pasteurella multocida, 215
Path ogen -associated m olecu lar pattern s
(PAMPs), 22 , 25
Path ogen icity, 30 , 30 31 , 31
Patien t h istory. See History
Patien t-related risk actors, m odi cation
o , 46 47
Pattern -recogn ition receptors (PRR), 22
PCT. See Procalciton in (PCT)
PDGF. See Platelet-derived grow th actor
(PDGF)
Pediatric patien ts
n egative pressu re w ou n d th erapy in , 275
osteom yelitis in , 423 428 , 424 427 ,
429 433 , 430 432 , 435 4 41 , 435 4 41 ,
4 43 4 45 , 4 43 451 , 4 47 451 , 453 460 ,
453 461
septic arth ritis in , 453 460 , 453 461
Pen icillin
com pou n ds in f u en cin g absorption an d
con cen tration o , 6 8
in n ecrotizin g so t-tissu e in ection s, 261
in open ractu res, 126
in septic arth ritis, 222
Pen icillin G, 70
Peptostreptococci, 42
Periph eral artery disease, 266
Periprosth etic join t in ection (PJI)
algorith m or, 202 2 05 , 2 02 2 05
am pu tation in , 2 02 , 205
in an kle, 4 09 413 , 4 0 9 413
case stu dy, 337 339 , 337 344 , 379 382 ,
379 382 , 383 38 9 , 383 39 0 , 391 398 ,
391 39 9 , 4 01 , 4 01 4 07 , 402 , 4 0 4 407 ,
4 09 413 , 40 9 413 , 415 , 415 421 , 418 , 419
classi cation o , 191
coated im plan ts in , 2 06 , 2 07
com orbidities in , 19 9 , 2 00
debridem en t in , 197 19 9 , 341 , 393 , 393 ,
4 03 , 410 , 410 , 417 418 , 418 , 421
diagn osis i , 192 19 6 , 193 19 6
in elbow, 415 , 415 421 , 418 , 419
etiology o , 18 9
exch an ge arth roplasty or, 19 9 2 01 , 20 0 ,
2 01
in h ip, 20 4 , 2 05 , 337 339 , 337 344 ,
379 382 , 379 382
im agin g in , 19 6 , 19 6
in ciden ce o , 18 9
irrigation in , 197 19 9
in kn ee, 2 04 , 2 05 , 383 38 9 , 383 390 ,
391 39 8 , 391 39 9
laboratory tests in , 194 195 , 195
localization o , 18 9
McPh erson classi cation o , 191
patien t h istory in , 192 193
perioperative an tibiotics an d, 19 0 191
pu ru len ce in , 195
reten tion in , 197 19 9
risk actors or, 19 0 , 19 0 191 , 192
salvage procedu res in , 2 01 2 02 , 205
in sh ou lder, 4 01 , 401 407 , 4 02 , 4 04 407
sym ptom s o , 192 , 192
syn ovial f u id an alysis in , 195
tim e rom in ection on set in , 2 03
treatm en t option s or, 19 6 2 05 , 2 0 0 205
van com ycin an d, 19 0 191
Zim m erli classi cation o , 191
PET-CT. See Positron -em ission tom ograph y
com pu ted tom ograph y (PET-CT)
PG. See Pyoderm a gan gren osu m (PG)
Ph arm acokin etics, o an tim icrobials in
bon e, 65
Ph en obarbital, 6 9
Ph en ytoin , 6 9
Ph ysioth erapy, in septic arth ritis, 223
Piperacillin , in septic arth ritis, 222
PJI. See Periprosth etic join t in ection (PJI)
PLA. See Polylactic acid (PLA)
Plain radiograph y. See Radiology; X-ray
Plate an d screw xation
o open ractu res, 133 , 133 , 147 , 147 148 ,
148
rem oval o , in tibia, 30 0 , 30 0
Platelet-derived grow th actor (PDGF), 267 ,
26 8
PMMA. See Polym eth ylm eth acrylate (PMMA)
PNAG. See Polym erized-N-acetylglu cosam in e
(PNAG)
Polyeth ylen e glycol (PEG), 10
Polyh exan ide, 7 7
Polylactic acid (PLA), 86
Polym erase ch ain reaction (PCR), 107 108
Polym erization , in m atrix, 5
Polym erized-N-acetylglu cosam in e (PNAG), 5 , 7
Polym eth ylm eth acrylate (PMMA), 79 , 80 ,
8 0 85 , 82 84 , 127 , 127 , 157
Positron -em ission tom ograph y com pu ted
tom ograph y (PET-CT)
in diagn osis, 103
in ractu re in ection , 154 , 154
Posterior iliac crest, as h arvestin g site, 175
Povidon e-iodin e, 48 , 49 , 78
Preem ptive an tibiotics, 6 4
Pressu re u lcers, 267 . See also Wou n ds
Preven tion
albu m in in , 10
an tibiotic proph ylaxis in , 55 , 55 56
atrau m atic su rgical tech n iqu e in , 51 52
basics o , 45 46 , 46
drapin g in , 49 , 49
h air rem oval in , 48
h an d h ygien e in , 49 50
in stru m en t sterilization in , 53
in traoperative m easu res in , 51 53
lam in ar airf ow in , 53
n asal decolon ization in , 47
an d n u m ber o people in operatin g
room , 53
patien t-related risk actors in , 46 47
postoperative m easu res in , 54
preoperative m easu res in , 46 50 , 48 50
o septic arth ritis in an terior cru ciate
ligam en t su rgery, 233
silver in , 10
skin clean sin g in , 47
skin preparation in , 48 , 48 49
sm okin g cessation in , 46
su rgical attire in , 50 , 50
o su rgical-site in ection s, 256
Proben ecid, 68
Procalciton in (PCT), 93
Proph ylactic an tibiotics, 55 , 55 56 , 6 4 , 10 6
Propionibacterium acnes, 30 , 31
pro le o , 41 , 41
in son ication , 112
Propionibacterium spp., h an d scru bbin g an d, 50
Prosth etic h eart valves, 56
Protease in h ibitors, 6 9
Proteases, 7
PRR. See Pattern -recogn ition receptors (PRR)
Pseudomonas aeruginosa, 30 , 33
h an d scru bbin g an d, 50
pro le o , 4 0 , 40
resistan ce in , 6 6
in septic arth ritis, 215 , 215 , 221 , 222
Pyoderm a gan gren osu m (PG), 259
R
Radial ractu re, ch ron ically in ected, 345 ,
345 350 , 346 , 349
Radiation th erapy, 266
Radiology
in diagn osis, 92 , 97 104 , 98 10 4
in ractu re in ection , 152 154 , 152 154
in in ected n on u n ion , 171 172
in periprosth etic join t in ection , 19 6 , 19 6
in septic arth ritis, 97 , 101 , 216 , 229
in septic bu rsitis, 253 254
in skin an d so t-tissu e in ection s, 247 , 259
in spon dylodiscitis, 237
479
 Inde x

RANKL, 11 arth ro brosis in , 232 , 232 Septic bu rsitis, 253 255

Ream ed lock n ail, in tibia, acu tely arth roscopic lavage in , 229 Sh ort-ch ain exocellu lar lipoteich oic acid
in ected, 283 28 6 , 283 287 articu lar cartilage dam age in , 232 , 232 (sce-LTA), 195
Rein ection , 11 com plication s w ith , 232 , 232 Sh ou lder arth roplasty, im plan t rem oval in
Resistan ce, 32 , 32 33 debridem en t in , 230 , 230 in ected, 4 01 , 401 407 , 4 02 , 4 04 407
Rib, as ree vascu larized bon e gra t diagn osis o , 227 229 , 228 , 229 Sickle cell disease, 26 6 , 426
sou rce, 183 epidem iology o , 227 Silden a l, 68
Ri am pin , 36 gra t preservation in , 230 , 230 Silver, 10 , 8 6
bioavailability, 71 gra t rem oval in , 230 , 230 Sin u s tracts, 106
com pou n ds in f u en cin g absorption an d in dication s or su rgical m an agem en t Skin an d so t-tissu e in ection s (SSTIs). See also
con cen tration o , 6 8 o , 229 Wou n ds
cotrim oxazole an d, 6 9 in dolen t presen tation o , 228 abscess, 253
dose, 71 irrigation in , 230 algorith m , 248
doxycyclin e an d, 6 8 laboratory tests in , 228 an tibiotics or, 249
in im plan t-associated in ection s, 72 m icroorgan ism s in , 227 biosu rgery in , 250
im portan ce o con tin u ation o , 67 ou tcom es in , 233 carbu n cles, 252
as local an tibiotic, 79 postoperative m an agem en t o , 232 cellu litis, 252 , 252
m in ocyclin e an d, 6 8 preven tion o , 233 classi cation o , 245 , 245 246
in osteoarticu lar in ection s w ith ou t oreign radiology in , 229 , 229 clin ical m an i estation o , 247
body m aterial, 72 reh abilitation or, 232 com plicated, 245
in septic arth ritis, 222 syn ovial f u id aspiration , 229 depth o , 246 , 246
spectru m , 71 tim e to presen tation o , 227 diagn osis o , 247 248
u se o , 72 , 73 tw o-staged revision in , 230 , 230 di eren tial diagn osis o , 248
Risk actors X-ray in , 229 , 229 epidem iology o , 246
m odi cation o patien t-related, 46 47 algorith m , 218 erysipelas, 251 , 251
or periprosth etic join t in ection , 19 0 , an tim icrobial treatm en t o , 221 , 222 etiology o , 247
19 0 191 , 192 arth rotom y in , 220 u ru n cles, 252
or septic arth ritis, 213 , 214 calorim etry in , 110 h istory in , 258 259
or skin an d so t-tissu e in ection s, 246 case stu dy, 453 460 , 453 461 h yperbaric oxygen or, 249
247 , 247 cell cou n ts in , 94 im agin g in , 247
or spon dylodiscitis, 235 , 236 , 239 , 239 clin ical exam in ation in , 216 , 216 laboratory tests in , 247
or su rgical-site in ection s, 45 , 45 diagn osis o , 216 , 216 217 , 217 m icrobiology o , 247
or w ou n d n on h ealin g, 265 , 266 di eren tial diagn osis o , 216 , 216 n ecrotizin g, 257 26 0 , 257 26 0
Riton avir, 6 9 etiology o , 213 n egative-pressu re w ou n d th erapy in , 250
Rotator cu repair, h u m eru s in ection in em u r, 453 460 , 453 461 n on su rgical treatm en t o , 249
a ter, 293 , 293 29 6 , 294 in ractu re in ection , 159 ph ysical exam in ation in , 247
Rou tes, o im plan t-associated in ection , 9 im agin g in , 216 plastic su rgery in , 250
in ciden ce o , 214 risk actors, 246 247 , 247
irrigation in , 218 septic bu rsitis, 253 255
S join t aspiration in , 219 speci c m an i estation s o , 251 , 251 26 0 ,
Salmonella, 426 laboratory tests in , 216 252 , 257 26 0
Salvage procedu res, in periprosth etic join t location s o , 214 as su rgical com plication , 255 256
in ection , 201 202 , 2 05 m agn etic reson an ce im agin g in , 101 su rgical treatm en t o , 250 , 250
Sarcoidosis, 216 m icrobes in , 214 215 , 215 in trau m a, 256 257
Scan n in g electron m icroscopy, im plan t- oligoarth ritis in , 214 treatm en t o , 248 , 248 250 , 250 , 260
associated bio lm in , 3 , 4 , 6 in pediatric patien t, 453 460 , 453 461 u n com plicated, 245
Scapu la, as ree vascu larized bon e gra t ph ysioth erapy in , 223 an d u rgen cy o su rgical action , 245 , 245
sou rce, 183 , 18 4 procalciton in in , 93 Skin clean sin g, in preven tion , 47
sce-LTA. See Sh ort-ch ain exocellu lar progn osis in , 223 Skin gra ts, or open w ou n ds, 269 , 269
lipoteich oic acid (sce-LTA) Pseudomonas aeruginosa in , 215 , 215 Skin preparation , in preven tion , 48 , 48 49
Scin tigraph y radiology in , 97 , 101 Slim e layer. See Extracellu lar polym eric
in diagn osis, 10 4 , 10 4 risk actors, 213 , 214 su bstan ce (EPS)
in in ected n on u n ion , 171 scin tigraph y in , 216 Sm all-colon y varian ts (SCV), 12 , 33 , 6 6
in periprosth etic join t in ection , 19 6 stagin g o , 219 Sm okin g, 45 , 46 , 167 , 26 6
in septic arth ritis, 216 sym ptom s o , 216 Socioecon om ic backgrou n d, osteom yelitis
SCV. See Sm all-colon y varian ts (SCV) syn ovectom y in , 221 an d, 423
Secon dary in ten tion , h ealin g by, 54 syn ovial f u id an alysis in , 217 , 217 So t-tissu e in ection s. See Skin an d so t-tissu e
Septic arth ritis treatm en t ailu re in , 220 in ection s (SSTIs)
a ter an terior cru ciate ligam en t su rgery treatm en t o , 218 220 , 218 223 , 222 Son ication , 111 113 , 111 114
algorith m , 230 X-ray in , 97 Son ograph y, in diagn osis, 103 , 103
an tibiotic th erapy in , 230

480 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns

Inde x

Spin e. See Spon dylodiscitis Staphylococcus lugdunensis, 36 Tibial ractu re

Spon dylodiscitis Staples, 52 ch ron ically in ected, 319 , 319 324 , 323 ,
de n ed, 235 Statin s, 69 325 328 , 325 329
diagn osis o , 236 , 237 Steel, stain less, titan iu m vs., 9 10 in ected n on u n ion in , 36 9 377 , 36 9 378
di eren tial diagn osis o , 236 Sterilization , o in stru m en ts, 53 Tibial n ail, acu tely in ected, 283 28 6 , 283 287
epidem iology o , 236 Steroid u se, 167 Tissu e h an dlin g, 51
im agin g in , 237 Stills disease, 216 Tissu e oxygen ation , 51
in ciden ce o , 236 Streptobacillus monili ormis, 215 Titan iu m , stain less steel vs., 9 10
laboratory tests in , 237 Streptococci, 36 , 36 37 TJR. See Total join t replacem en t (TJR)
n on operative treatm en t o , 237 Streptococcus agalactiae, 36 TKA. See Total kn ee arth roplasty (TKA)
ou tcom es w ith , 241 Streptococcus mutans, 5 , 36 TLRs. See Toll-like receptors (TLRs)
path ogen esis o , 235 Streptococcus oralis, 192 TNF. See Tu m or n ecrosis actor (TNF)
risk actors, 235 , 236 , 239 , 239 Streptococcus pneumoniae, 36 Tobram ycin
sym ptom s, 236 Streptococcus pyogenes, 36 , 249 as local an tibiotic, 79
treatm en t o , 237 24 0 , 238 24 0 Streptococcus spp., in septic arth ritis, 222 in open ractu res, 127
X-ray in , 237 Streptococcus viridans, 36 , 192 Toll-like receptors (TLRs), 10 , 11 , 22
SSIs. See Su rgical-site in ection s (SSIs) Su crose, in m atrix, 5 Total an kle arth roplasty (TAA), im plan t
SSTIs. See Skin an d so t-tissu e in ection s Su gars, in m atrix, 5 rem oval in acu tely in ected, 40 9 413 ,
(SSTIs) Su ppressive th erapy, 65 40 9 413
Staph ylococci, 35 , 35 36 Su rgical attire, 50 , 50 Total elbow arth roplasty (TEA), im plan t
Staphylococcus aureus, 3 , 4 , 6 , 8 Su rgical-site in ection s (SSIs) rem oval in acu tely in ected, 415 , 415 421 ,
abscesses, 11 a ter spin e su rgery, 239 24 0 , 24 0 418 , 419
an tibiotic resistan ce an d, 32 33 case stu dy, 309 312 , 309 312 Total h ip arth roplasty (THA), ch ron ically
requ en cy o , in bon e an d join t classi cation o , 255 in ected, 379 382 , 379 382
in ection s, 29 debridem en t o , 295 , 310 , 310 Total join t arth roplasty (TJA). See Periprosth etic
h arborin g o , 29 de n ed, 255 join t in ection (PJI)
im m u n e im pairm en t by, 26 diagn osis o , 255 Total join t replacem en t (TJR), 3
m atrix w ith , 5 etiology o , 255 Total kn ee arth roplasty (TKA)
m eth icillin -resistan t in h u m eru s, a ter rotator cu repair, 293 , ch ron ic in ection in , 383 38 9 , 383 39 0 ,
in an tibiotic proph ylaxis, 55 293 29 6 , 294 391 398 , 391 399
in erysipelas, 251 im plan t rem oval in , 311 , 311 im plan t rem oval a ter, 391 398 , 391 399
lim ited resou rces treatm en t o , 463 levels o , 45 Toxic sh ock syn drom e (TSS), 259
467 , 463 468 m icrobiology o , 255 Trau m a. See also Wou n ds, open
in n asal decolon ization , 47 preven tion o , 256 (See also Preven tion ) n egative-pressu re w ou n d th erapy
in open ractu res, 126 rates o , 45 in , 274 275
polyh exan ide or, 7 7 risk actors, 45 , 45 skin an d so t-tissu e in ection s in , 256 257
polyh exan ide in , 7 7 Su tu res, in atrau m atic tech n iqu e, 51 Treponema denticola, 192
screen in g or, 72 Syn ovectom y, in septic arth ritis, 221 Trim eth oprim / su l am eth oxazole, in septic
in septic arth ritis, 213 , 221 , 222 Syn ovial f u id an alysis, in septic arth ritis, 217 , arth ritis, 222
in skin an d so t-tissu e in ection s, 249 217 , 229 Tropheryma whipplei, 215
in n asal decolon ization , 47 System ic an tibiotics. See An tibiotics TSS. See Toxic sh ock syn drom e (TSS)
n atu ral h abitat o , 29 , 30 Tu m or n ecrosis actor (TNF), 22 , 93 , 195
pro le o , 35 36
in septic arth ritis, 214 215 , 215 , 221 , 222 , T
227 TAA. See Total an kle arth roplasty (TAA)
U
on skin , 30 Targeted th erapy, 64 Ulcers. See Wou n ds
sm all colon y varian ts, 12 Tazobactam , in septic arth ritis, 222 Ultrasou n d. See Son ication ; Son ograph y
Staphylococcus epidermidis vs., 31 TEA. See Total elbow arth roplasty (TEA) Urease, 7
van com ycin -in term ediate sen sitivity Team w ork, 74
polyh exan ide or, 7 7 Tech n etiu m - 9 9 m , 10 4
viru len ce o , 31 Teicoplan in V
Staphylococcus epidermidis, 3 , 111 dose, 70 VAC. See Vacu u m -assisted closu re (VAC)
an tibiotic resistan ce an d, 32 33 in septic arth ritis, 222 Vacu u m -assisted closu re (VAC), 272
an tibiotics or, 4 05 spectru m , 70
m atrix w ith , 5 Tetracyclin e derivatives, 6 8
n atu ral h abitat o , 29 THA. See Total h ip arth roplasty (THA)
in periprosth etic join t in ection , 4 05 , 4 05 Tibia, osteom yelitis in , 357 36 0 , 357 36 0 ,
periprosth etic join t in ection an d, 193 429 433 , 430 432 , 4 43 445 , 4 43 451 , 4 47 451
pro le o , 35 36 Tibial delayed u n ion , w ith broken
in septic arth ritis, 227 im plan ts, 297 307 , 297 30 8
Staphylococcus aureus vs., 31
viru len ce o , 31

481
 Inde x

Van com ycin

in an tibiotic proph ylaxis, 55 , 55 W X
dose, 70 Wou n ds, open . See also Skin an d so t-tissu e X-ray
in ractu re in ection , 157 in ection s (SSTIs) in diagn osis, 97 , 98 , 9 9 , 101
as local an tibiotic, 79 , 83 , 83 8 4 adju n ctive th erapies w ith , 270 , 271 in ractu re in ection , 152 , 152
in n ecrotizin g so t-tissu e in ection s, 261 clin ical assessm en t o , 26 6 in in ected n on u n ion , 171
periprosth etic join t in ection an d, 190 191 coverage o , 26 9 , 269 270 in periprosth etic join t in ection , 19 6 , 19 6
in polym eth ylm eth acrylate beads, 83 , debridem en t o , 267 in septic arth ritis, 97 , 229 , 229
83 8 4 de n ed, 265 in spon dylodiscitis, 237
in septic arth ritis, 221 , 222 diabetic n eu ropath ic, 267
spectru m , 70 dressin gs or, 26 8 , 268
Van com ycin -in term ediate sen sitivity S. aureus f aps w ith , 270 , 271 Z
(VISA), polyh exan ide or, 7 7 h ealin g com plication s, 265 Zim m erli classi cation , 191
Van com ycin -resistan t en terococci (VRE), 37 h ealin g ph ases, 265
Vascu lar en doth elial grow th actor h yperbaric oxygen th erapy or, 270
(VEGF), 195 h yperten sive, 267
Vascu lar in su cien cy, 167 irrigation o , 267
Vascu larized bon e tran s er, in in ected isch em ic, 267
n on u n ion , 183 , 18 4 laboratory tests in , 26 6
VEGF. See Vascu lar en doth elial grow th actor m align an t, 267
(VEGF) m an agem en t o , 267 26 8 , 26 8
Ven ou s u lcers, 267 . See also Wou n ds n egative-pressu re w ou n d th erapy
Vertebral colu m n . See Spon dylodiscitis or, 272 276 , 274
Viru len ce, 30 , 30 31 , 31 pressu re, 267
VISA. See Van com ycin -in term ediate sen sitivity risk actors or n on h ealin g, 265 , 266
S. aureus (VISA) skin gra ts or, 26 9 , 26 9
Vitam in K an tagon ists, 6 8 , 6 9 topical th erapy or, 267
Vortexin g, 113 vascu lar exam in ation in , 26 6
VRE. See Van com ycin -resistan t en terococci (VRE) ven ou s, 267

482 Pr in cip le s o f Or t h o p e d ic In fe ct io n Ma n a ge m e n t Ste phe n L Kate s, Olivie r Bore ns