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Management of Orthopaedic Infections A Practical Guide AntoniaF.Chen,MD,MBA DirectorofResearchinArthroplasty DepartmentofOrthopaedicSurgery BrighamandWomen’sHospital; AssociateProfessorofOrthopaedicSurgery HarvardMedicalSchool Boston,Massachusetts,USA 79illustrations Thieme NewYork(cid:129)Stuttgart(cid:129)Delhi(cid:129)RiodeJaneiro LibraryofCongressCataloging-in-PublicationData Importantnote:Medicineisanever-changingscience isavailablefromthepublisher undergoingcontinualdevelopment.Researchandclini- calexperiencearecontinuallyexpandingourknowledge, inparticularourknowledgeofproper treatmentand drugtherapy.Insofarasthisbookmentionsanydosage orapplication,readersmayrestassuredthattheauthors, editors,andpublishershavemadeeveryefforttoensure thatsuchreferencesareinaccordancewiththestateof knowledgeatthetimeofproductionofthebook. 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Any use, exploitation, or commercialization PrintedinUSAbyKingPrintingCompany,Inc. 54321 outside the narrow limits set by copyright legislation withoutthepublisher’sconsentisillegalandliableto ISBN978-1-68420-133-4 prosecution.Thisappliesinparticulartophotostatrepro- duction,copying,mimeographingorduplicationofany Alsoavailableasane-book: kind,translating,preparationofmicrofilms,andelectronic eISBN978-1-68420-134-1 dataprocessingandstorage. Firstandforemost,Iwouldliketodedicatethisbooktomymother,JeanF.Lian,whohastaughtmeandraised metobecomethewomanthatIam.Mydedication,workethic,anddrivehaveallcomefromher,andIam eternallygratefulforeverythingthatshehasdoneforme. Secondly,Iwouldliketodedicatethisbooktomysisterandfriend,VictoriaChenNorland,whohas encouragedandsupportedmethroughouttheyears. Thirdly,Iwouldliketodedicatethistomyfather,Bor-KuanChen,whotaughtmealoveforscienceand scientificwriting. Andfinally,Iwouldliketodedicatethisbooktomymentors,friends,andcolleagueswhohavecontributedto thisbook,andthosewithwhomIlovesharingandgrowingtogetherinthefieldoforthopaedics. AntoniaF.Chen,MD,MBA Contents Videos......................................................................... xi Foreword .................................................................... xii Preface....................................................................... xiii Contributors................................................................. xiv 1. DetectionofMicrobesinOrthopaedicInfections.......................... 1 MichaelHenry,AndyO.Miller,andBarryD.Brause 1.1 Introduction..................... 1 1.2.4 OrthopaedicHardwareInfections.... 5 1.2.5 NativeBoneandJointInfections..... 8 1.2 Culture-BasedMicrobiology ..... 2 1.3 MolecularTechniques .......... 10 1.2.1 LimitationsofCulture-Based 1.3.1 PolymeraseChainReaction(PCR)... 10 Microbiology...................... 3 1.3.2 Next-GenerationSequencing(NGS) 12 1.2.2 DetectionofMicrobesinBiofilm..... 4 1.4 Conclusions .................... 13 1.2.3 InfectionswithAtypicalOrganisms .. 4 2. AntibioticsforOrthopaedicInfections..................................... 18 AlainaS.RitterandSandraB.Nelson 2.1 SystemicAntibiotics............ 18 2.3.2 Biodegradable.................... 27 2.4 AntibioticsforUseinCarriers... 28 2.1.1 Definitions....................... 18 2.1.2 AntibioticSelectionand 2.4.1 Gentamicin/Tobramycin........... 30 Administration................... 19 2.4.2 Vancomycin...................... 30 2.1.3 IntravenousversusOralAntibiotics . 21 2.5 TopicalAntibiotics.............. 30 2.2 Antiseptics..................... 25 2.6 TreatmentFailure............... 30 2.2.1 Povidone-Iodine.................. 25 2.2.2 Chlorhexidine 2.7 Collaborationbetween (Gluconate/Digluconate)........... 26 OrthopaedicSurgeonsand 2.3 CarriersthatmaybeAssociated InfectiousDiseaseSpecialists... 31 withAntibiotics ................ 26 2.8 Conclusion..................... 31 2.3.1 Nondegradable................... 26 3. IrrigationSolutionsforOrthopaedicInfections........................... 34 MichaelYayac,SamuelJ.Clarkson,CraigDellaValle,andJavadParvizi 3.1 AceticAcid..................... 34 3.3.1 OverviewofAntisepticAgent ...... 37 3.3.2 EfficacyasaSurgicalWoundIrrigant 38 3.1.1 OverviewofAntisepticAgents...... 34 3.4 Chlorhexidine .................. 39 3.1.2 EfficacyasSurgicalWoundIrrigant.. 35 3.2 BacitracinandPolymyxin....... 36 3.4.1 OverviewofAntisepticAgent ...... 39 3.4.2 EfficacyasaSurgicalWoundIrrigant 40 3.2.1 OverviewofAntisepticAgent ...... 36 3.5 SodiumHypochlorite(NaOCl)... 40 3.2.2 EfficacyasaSurgicalWoundIrrigant 36 3.3 DilutePovidone-Iodine(PI) ..... 37 3.5.1 OverviewofAntisepticAgent ...... 40 vii Contents 3.5.2 EfficacyasaSurgicalWoundIrrigant 41 3.6.2 EfficacyasaSurgicalWoundIrrigant 42 3.6 HydrogenPeroxide............. 41 3.7 Conclusion ..................... 42 3.6.1 OverviewofAntisepticAgent ...... 41 4. SurgicalWoundDressingsafterTreatingOrthopaedicInfections....... 46 PatrickMoodyandBryanSpringer 4.1 Introduction.................... 46 4.3.2 DressingApplicationTipsandTricks 52 4.3.3 WoundVacuumSystems........... 53 4.2 CharacteristicsofOptimal 4.4 AlgorithmforSurgicalDressing SurgicalDressings.............. 47 Selection....................... 57 4.3 DressingTypes ................. 48 4.5 Conclusion ..................... 58 4.3.1 NonocclusiveandOcclusive Dressings........................ 48 5. Osteomyelitis................................................................ 61 MartinMcNally 5.1 Introduction.................... 61 5.6 Microbiology................... 73 5.2 Terminology.................... 62 5.7 TreatmentofOsteomyelitis..... 75 5.3 Classification................... 64 5.7.1 GeneralConsiderations............ 75 5.7.2 AcuteOsteomyelitis............... 77 5.3.1 Type1(Medullary)................ 64 5.7.3 ChronicOsteomyelitis............. 77 5.3.2 Type2(Superficial)............... 66 5.7.4 OperativeTreatment.............. 78 5.3.3 Type3(Localized)................. 68 5.7.5 TissueSampling.................. 79 5.3.4 Type4(Diffuse) .................. 68 5.7.6 TissueExcision................... 79 5.4 Diagnosis....................... 69 5.7.7 AntimicrobialTherapy............. 81 5.4.1 ClinicalFeatures.................. 69 5.7.8 DeadSpaceManagement.......... 82 5.4.2 LaboratoryTests.................. 69 5.7.9 BoneStabilization ................ 82 5.4.3 Imaging......................... 69 5.7.10 Soft-TissueCoverage.............. 85 5.4.4 MicrobiologicalDiagnosis.......... 72 5.7.11 StagingofSurgery................ 85 5.4.5 HistologicalDiagnosis............. 72 5.8 Conclusion ..................... 85 5.5 DiagnosticCriteria.............. 73 6. TreatmentoftheSepticNativeJoint....................................... 88 TimothyL.TanandSommerHammoud 6.1 Introduction.................... 88 6.3.1 CommonOrganisms .............. 93 6.3.2 GonococcalArthritis.............. 94 6.2 Diagnosis....................... 89 6.3.3 OtherPathogens.................. 94 6.2.1 RiskFactors...................... 89 6.3.4 AntimicrobialTherapy............. 94 6.2.2 JointInvolvement................. 90 6.3.5 SurgicalTreatment................ 95 6.2.3 ClinicalManifestations............ 90 6.3.6 NeedleAspiration................. 95 6.2.4 SerumEvaluation................. 91 6.3.7 ArthroscopicTreatment........... 95 6.2.5 SynovialAnalysis................. 91 6.3.8 OpenTreatment.................. 96 6.2.6 Imaging......................... 93 6.4 Conclusion ..................... 98 6.3 Treatment...................... 93 viii