team. Elective surgery should, when possible, be postponed until the pre-existing conditions are improved. Medication of patients with known diabetes and suboptimal glucose sugar levels should be adjusted preoperatively whenever pos­sible to reach normal glucose levels, and there­fore reduce the risk of infection.

12]) are related to the occurrence of infections of

Especially in nosocomial infections, multire­sistant bacteria like methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas and Enterobacteria can be found [25]. These pathogens present their own unique challenges, as antibiotic treatment is often complicated for treatment of these particular infections. Preferably, these patients should be treated in specialised centres by an experienced, multidis­ciplinary team.

In contrast, exogen osteitis and septic arthritis are often multibacterial infections after trauma as well as iatrogenic after surgeries (e.g. surgical site infection). For that reason, treatment is often challenging and requires a different approach [38].

By denition of the CDC acute bone and joint infections after surgery are limited to a time period of 30 (acute onset) to up to 90 days within 1year if an implant is in place (late onset [3]). In the early stage, patients normally com­plain of local symptoms like redness, swelling, pain at the operation site and systemic reactions like fever, fatigue and general sickness. The onset is typically within a short time period. Wounds might present with secretion and pos­sibly pus. As already stated, the critical incident in bone infection is the development of a bio­lm, especially if osteosynthesis hardware or prosthesis with plastic components are in situ [27]. Biolm prevents an effective antibiotic treatment and builds a hard-to-penetrate layer for the human (cellular) immune system and antibiotic drugs to destroy bacteria. The deni­tive formation of this biolm occurs early after the start of infection, over the time of days to weeks, so the timeframe is essential in the suc­cessful treatment of these infections. An acute infection leads to a quick and strong immune response. Histologic ndings include erosions and destruction of bone and neutrophils [44]. Underlying conditions such as diabetes benet the rapid expansion of the infection due to lack of adequate perfusion and reduced immune response [5]. In fracture-related infections, inadequate xation and/or soft tissue damage favor the occurrence of an acute or ongoing per­sistent infection like osteomyelitis. This is aggravated in patients with extensive soft tissue damage and according to Gustilo Anderson’s Classication in Grade II and III open fractures. To reduce the risk of an acute or an ongoing infection, adequate wound and soft tissue man-

agement from the early start in open fracture treatment, for example with negative pressure wound therapy, is mandatory [45].

Chronic infection will develop more easily if the local vascularisation of soft tissue and bone is compromised. To reduce the initial bacterial bur­den in an open trauma wound and/or fracture and to reduce the risk of an ongoing infection, mod­ern techniques like negative pressure wound ther­apy can support a faster and better clinical outcome [48–51]. By use of two different types of reticulated foam with different physical and mechanical properties (polyurethane or polyvi­nylalcohol foam) in the wound, the wound,