Penetration of linezolid into bone and joint tissues was studied by high-performance liquid chromatography in 13 patients suffering from implant-associated infections with methicillin-resistant staphylococci. Mean concentrations of linezolid in infected tissues were greater than 10 mg/liter in a sampling time range of 35 to 124 min after administration of the preoperative dose, except in bone specimens, where they reached 3.9 ؎ 2.0 mg/liter.
We analysed the long-term results of arthrodesis of the shoulder after infection in 15 patients. At the time of operation, 14 cultures were positive for Staphylococcus aureus. The mean follow-up was 8.3 years (3 to 14) and 90% of the patients were satisfied with the outcome. There were complications in five patients (33%); in three there was nonunion with loosening of the implant. One patient had a sound bony union but with a persistent sinus six years after arthrodesis and another had a sinus which healed after the metal was removed. Four of these five patients (80%) were heavy smokers (> 20 cigarettes/day). Cancellous bone grafting did not affect the incidence of complications. The mean age of the patients with complications was 58.6 v 48.6 years for those without (p = 0.2808 ; not significant). Those with complications had had more previous operations (6.4 v 2.5, p < 0.05). Antibiotics, as determined by the bacteriological cultures, were administered for six weeks. The complication rate was higher in patients with active sepsis but the younger the patient and the fewer number of previous operations (< 50 years, < four previous operations), the better was the outcome. Considering the rate of complications, we recommend early surgery in these patients.
Infection of the bone is one of the most serious complications in the field of orthopedic and trauma orthopedic surgery. Sufficient treatment protocols not only contain complex surgical procedures but also sophisticated diagnostic tools, proper use of antibiotics, and intensive physical therapy right from the beginning. Even in light of these advanced treatment protocols, which have great impact on both patients and health care systems, persisting infection and residual functional deficits of the extremities are not rare. In cases of early (acute) infection, the main objective is to avoid chronification by diligent surgical interventions. The surgical principle is the meticulous debridement and lavage of the situs. Revision of only the epifascial layers is as inadequate as the simple reopening of the wound without excision of the whole wound including all tissue layers. In cases of chronic soft tissue and bone infection, radical debridement of all infected and scar tissue is also the basic requirement of treatment. Reconstruction of the soft tissue envelope is done by local or free flap surgery. Because of they are better resistant to infection, musculo(cutaneous)flaps are preferred. Bony reconstruction is done by autologous cancellous bone grafting (partial defects), segment transport (full thickness defects), or freely transplanted vascularized bone grafts (large partial defects). Both soft tissue and osseous reconstruction take a relatively long period of time requiring several operations and periods of hospitalization. These have to be discussed and explained to the patients extensively. If the required amount of resection and the capability of reconstruction do not coincide, the surgeon and the patient have to decide whether restoration of function without definitive infection care, symptomatic infection therapy, or amputation is the most proper treatment option according to the patient's everyday needs and lifestyle. Because each treatment protocol is a composition of orthopedic trauma surgeons, plastic surgeons, radiologists, microbiologists, and physical therapists, reliable cooperation and communication is essential.
Arthrodesis is a well-recognized salvage procedure in patients with septic destruction of knee joints. It offers the opportunity for restoring weight bearing capability and significant pain relief as well as eradication of infection, but at the expense of joint motion. However, arthrodesis in order to joint sepsis may be difficult to achieve because of poor bone stock, persistent infection and soft tissue compromise. From 2000 to June 2004, in 70 consecutive patients arthrodesis of the knee was indicated. Nineteen patients were considered to have external hybrid fixator (EHF) and were therefore included to the prospective study protocol. Forty-three stabilisations of destructed knee joints were done by a modular titanium rod. In these cases bony fusion was very unlikely to be achieved because of devastating defects due to infected total knee arthroplasties. Eight patients were treated by compression nailing. In these situations EHF was not indicated. In three patients minor complication occurred. In two out of 17 patients fusion failed because of primary underestimated bony defects (11.8%). The use of EHF for arthrodeses after septic destruction of knee joints can be recommended according to our results. However, EHF will not be successful or applicable in each case. Therefore, physicians and institutions that offer this special method should have not only experiences with EHF but also with arthrodeses and alternative procedures.
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