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27 Infective Complications After Open Fractures
397
patient’s immune system is compromised, both
tetanus toxoid and HTIG should be administered [40]. The HTIG will offer most patients
3weeks of protection.
Duration ofAntibiotic Administration
The ideal duration of antibiotic administration
has been controversial. A 2017 systematic
review by Messner etal. could not support the
administration of antibiotics for longer than
72hours following an open long-bone fracture
[41]. A 2019 study discovered a correlation
between extended antibiotic prophylaxis
(>72hours after denitive wound closure) and
an increase in surgical-site infections (SSIs) in
mildly contaminated wounds, but a signicant
reduction in SSIs in severely contaminated
wounds [42]. A 2020 review article also could
not support antibiotic administration beyond
24 hours after either debridement with sterile
dressings or denitive coverage [43].
Timing
Early antibiotic prophylaxis has been identied
as the single most important factor in preventing
infection and further complications [44]. Earlier
studies recommended administration within
3 hours of facility presentation; however, more
recent studies suggest a stricter guideline of
administration within 1hour [45].
Local Antibiotics
Local antibiotics may be benecial for the treatment of certain open fractures. Antibiotics placed
in the zone of injury can achieve high local drug
concentrations, typically without systemic side
effects [46].
27.10.1.3 Meticulous Injury Zone Excision (Debridement)
In general, the purpose is to eliminate damaged
tissue that could serve as a bacterial breeding
ground without causing extensive additional surgical trauma through unnecessary periosteal
stripping or undermining of skin aps.
Debridement of an open fracture must be performed cautiously so as to avoid leaving behind
devitalized tissue or contamination.
(a) Traumatic wounds must be extended, and
muscle compartments opened and explored.
(b) The skin edges should be trimmed to a
healthy bleeding edge.
(c) Loose subcutaneous fat should also be
removed, along with any severely contused
or noncontractile muscle.
(d) Bone should also be removed if it is free of
soft-tissue attachment. Major articular fragments may be an exception to this rule;
whenever possible, they should be retained
so that attempts can be made to restore joint
stability and motion.
Timing ofDebridement
The timing of surgical irrigation and debridement
remains a controversial topic. Traditionally,
6hours was regarded as a traditional for reduce
the risk of infection following an open fracture.
Multiple studies indicate that early surgical irrigation and debridement should be emphasized to
reduce the risk of infection. Surgical treatment
should be administered no later than 24 hours
post-injury for open fractures of grades I and II,
and within 12hours for open fractures of grade
III, although earlier treatment may be preferred
[47, 48].
Irrigation
Irrigation combined with debridement assists in
removing contamination from open fractures and
reducing the risk of infection. The uid lavage of
open wounds (FLOW) study compared and contrasted various lavage uids and irrigation pressures. They discovered that, regardless of
irrigation pressure, normal saline solution
appeared to reduce the reoperation rate [49].
Other studies suggest that low-pressure irrigation
with saline offers an effective, low-cost option
for the irrigation of open fractures [50].
It has been demonstrated that the addition of
antiseptics, surfactants, or antibiotics to the uid
is inferior to normal saline in preventing infection and limiting the rate of reoperation [50]. The
ideal volume of irrigant has not been determined
[50]. An example of a common regimen calls for
3, 6, and 9L of irrigant for grade I, II, and III
fractures respectively [51].
398
K. M. Emara et al.
27.10.1.4 Fracture Stabilization
The injured patient receives numerous benets
from the prompt stabilization of open fractures. It
protects the soft tissues surrounding the injury
site from further damage caused by mobile fracture fragments. Additionally, length, alignment,
and rotation are restored. This restoration of
length also aids in the reduction of soft tissue
dead spaces which has been demonstrated in
studies to reduce infection rates in open fractures
[52]. Lastly, early xation allows improved
access to soft tissues surrounding the injury and
facilitates the patient’s early return to normal
function [53].
When selecting xation constructs, the surgeon has numerous options, including skeletal
traction, external xation, and intramedullary
nails and plates. The choice of xation depends
on the fractured bone and its location (intraarticular, metaphyseal, diaphyseal), the degree of
soft-tissue injury and contamination, and the
patient’s physiologic status [54].
It appears that grades I and II open fractures
can be treated similarly to grades I and II closed
fractures, with appropriate antibiotic prophylaxis, wound debridement, and closure [55], and
in the case of tibial fractures, the use of reamed
intramedullary nails seems reasonable [56].
In the management of grade III open fractures, there are more controversies. In grade
IIIA fractures with minimal bone defect, the
use of non- reamed intramedullary nails appears
to be a good and safe option (superior) compared to temporary external xation, with minimal complications and good union rates [57].
In grade IIIB open tibial fractures, recent
research indicates that reamed nailing is functionally equivalent to unreamed nailing [58]. If
we are in the presence of a bone defect, the use
of a protocoled treatment with temporary
external xation may be useful for denitive
treatment. Conversion from external xation to
an intramedullary nail is safe given two parameters: conversion in less than 2 weeks and
absence of pin site infections. Conversion after
pin site infections may require additional time
and antibiotic treatment after removing the
external xator and placement of the intramedullary nail [59].
27.10.1.5 Second Look
Forty-eight hours after the original debridement,
it is generally advisable to reinspect the injury
zone under anesthesia. This affords the opportunity to:
• Assess the viability of the soft tissues.
• Conduct any necessary further tissue
excision.
• Wash out any accumulated blood clot, tissue
uid coagulum, or remaining foreign
material.
27.10.1.6 Soft Tissue Closure
Options for wound closure in the treatment of
open fractures include primary closure of the
skin, split-thickness skin-grafting, and the use of
either free or local muscle aps.
Timing ofPrimary Closure
(a) Immediate (at the time of the initial surgical
intervention) certain criteria should be met
[60]:
• Debridement performed within 12h.
• No excess skin loss primarily or secondarily during debridement.
• Skin approximation is possible without
tension.
• No gross soil or other similar
contamination.
• No vascular insufciency.
(b) Early (within the 24–72h window).
(c) Delayed (closure extends beyond 3days).
Contraindications ofPrimary Closure
• Gross contamination, stagnant water contamination, and farm injuries or freshwater boating
injuries.
• Delay of 12hours after injury for delivery of
antibiotics.
• Confounding comorbidities.
• Doubt about the adequacy of the initial
debridement [8].
27 Infective Complications After Open Fractures
399
Closure with local, or free aps is appropriate
for larger and more complicated wounds and for
open joints, as soon as staged wound excision is
complete. It is important to close a complex wound,
especially involving a joint, as soon as the wound
appears healthy (preferably at 5–7 days), rather
than to leave it open and risk hospital infection.
27.10.2 Negative Pressure Wound
Therapy (NPWT)
Used in dealing with open fracture wounds and
may decrease the need for free tissue transfer or
rotational ap coverage in high-energy open fractures [61]. Negative wound therapy is an option
for the temporary closure of wounds in patients
whose conditions preclude reconstruction (e.g.
polytrauma patients who are not suitable for
surgery).
27.10.2.1 Advantages
1. Reduce the risk of infection and accelerate
wound healing in open fractures [62].
2. Decreased the incidence of deep infection and
ap failure as compared with conventional
dressings after open fractures that were not
amenable to early closure [63].
In many cases, abundant granulation tissue
forms after NPWT, and residual soft-tissue
defects can be covered effectively with basic skin
grafts.
It represents a relatively easily assessable
scoring system, where values of >7 are absolute
predictable for amputation.
27.10.4 Management ofEstablished
Infection
The most effective method to prevent infection in
open fractures is optimal primary treatment. In
the case of an established infection, surgical
treatment must concentrate on eradicating the
inamed area completely. Management of
acutely infected wounds is primarily surgical,
relying on removal of remaining foreign bodies
and debris, debridement of necrotic and devascularized tissue, and drainage of uid collections.
Orthopaedic hardware is frequently affected,
which would ideally be removed or replaced
given biolm involvement.
Typically, empiric antimicrobial treatment is a
broad spectrum, but therapy should be as narrow
as possible based on culture data.
The duration of antibiotic therapy is determined by the depth and extent of the infection;
superficial wound infections may require
nothing except debridement, deep-wound
infections frequently require 1–2 weeks of
systemic antibiotics, and osteomyelitis typically requires 4–6weeks of therapy, which is
frequently prolonged when orthopedic hardware is involved [65].
27.10.3 Primary Amputation inOpen
Fractures
Primary amputation must be considered in most
severe soft tissue damage, to avoid prolonged
disability and a limb without function after many
reconstruction attempts. Discrimination between
salvageable or non-salvageable extremities may
be supported by the Mangled extremity severity
score [64].
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Infections inOrthopedic Oncology
AlbertoCrimì, ElisaPala, GiuliaTrovarelli,
AndreaAngelini, andPietroRuggieri
28
28.1 Introduction
This chapter focuses on Infections in Orthopedic
Oncology in those cases when there is no reconstruction after tumor resection, after curettage
surgeries, and when the reconstruction after
resection is not a prosthetic reconstruction. The
wider topic of infections in Megaprosthesis is
discussed in another chapter of this book.
The rate of Surgical Site Infections (SSI) in
Orthopaedics ranges between 0.2% and 4.2%, it
is lower in arthroplasties (around 0.2%) [1] and
higher in spine surgery (reaching 4.2%) [2, 3]. In
Orthopaedic Oncology the infection rate is higher
[4–19] than in Traumatology and standard
Orthopaedics, due to the different typology of
patients, the associated therapies (chemotherapy
and radiation therapy), and the often more invasive surgery (Fig.28.1).
While the rate of infection in megaprosthesis
is well studied and ranges between 9.3% and
20.4% [4, 5], depending on the site of the prosthetic reconstruction [20], the infections in other
types of Orthopaedic Oncology surgeries have
been described in the scientic literature, but
A. Crimì · E. Pala · G. Trovarelli · A. Angelini ·
P. Ruggieri (*)
Department of Orthopedic and Orthopedic Oncology,
University of Padova, Padova, Italy
e-mail: alberto.crimi@aopd.veneto.it;
elisa.pala@unipd.it; giulia.trovarelli@unipd.it;
andrea.angelini@unipd.it; pietro.ruggieri@unipd.it
with a less homogeneous approach compared to
the megaprosthesis, and usually presented not as
a standing alone topic but together with outcomes
and other complications.
The analysis of infection risk in Orthopaedic
Oncology shows a higher patient-specic risk of
SSI in case of malignancy, smoking history, and
a higher American Society of Anesthesiologists
(ASA) score. While procedure-specic risk factors for SSI are considered surgical time, blood
loss, blood transfusion volume, neoadjuvant chemotherapy, neoadjuvant radiation therapy, inpatient type of surgery, and number of previous
surgeries on the same site [21]. These last two
factors are highlighted to be independent predictors of SSI.Another study shows the same risk
factors, adding to the list of risk factors also age,
preexisting implants, concomitant infection at
another site, and body mass index (BMI) [22].
As presented in the previous paragraph both
Radiation Therapy (XRT) and Chemotherapy
(CHT) are considered a risk factor for SSI in
Orthopaedic Oncology.
XRT is considered a risk factor for SSI
because of subsequent tissue damage, it has
been studied in the scientic literature but its
real inuence on post-operative infections is
still debated and only few papers focused specically on this topic [5, 22–24]. Some studies
[23, 24] do not demonstrate a statistically signicant increased risk of infection after XRT,
while in another study XRT is found to be asso-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
P. Ruggieri et al. (eds.), Bone and Joint Infections, https://doi.org/10.1007/978-3-031-96383-4_28
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A. Crimì et al.
ab
Fig. 28.1 Wide surgical exposure is required for resection of a (a) large Synovial Sarcoma of the popliteal fossa with
(b) neurovascular structures identication and protection
ciated with a higher risk of SSI in spine metastatic tumors [5], a signicantly higher risk of
SSI is also highlighted in a series of 1034
patients who had preoperative XRT and in
patients with a remote history of XRT [22].
CHT is considered a s risk factor for SSI
because it can induce leukocytopenia and neutropenia, also in this case the real inuence of
CHT on SSI is debated. Neoadjuvant CHT is
considered a risk factor for SSI in all types of
cancer surgeries [25]. In Orthopaedic Oncology
there are some works reporting CHT as a risk
factor for SSI [21, 22, 24, 26], but there are
some works that do not report a statistically signicant higher risk of SSI in patients who had
CHT [23, 27, 28], in these last studies more than
CHT itself a lower number of White Blood Cells
(WBC) is correlated with a higher risk of SSI.In
the studies supporting the correlation between
CHT and SSI, in a rst study on 1521 patients
[22
], a post- operative CHT in the rst month
after surgery was associated with a higher risk
of SSI, in another study [21] there an SSI rate of
34% was found in patients who had neoadjuvant-CHT while the rate in patients who did not
have neoadjuvant- CHT was 13%, with a statistically signicant difference. A CHT-associated
preoperative lower count of WBC was found to
be a predictor for SSI in patients with allograft
reconstruction after resection of the proximal
tibia [26].
SSIs have terrible consequences, bringing the
burden of longer hospital admission times, worse
function, higher costs for the health system (long
times of expensive antibiotics administration,
multiple surgeries, difcult reconstructions), and
increased mortality (also considering the possible
effect of delaying pivotal treatment as chemotherapy and radiation therapy [29].
28.2 Infections inResection
without Reconstruction
28.2.1 Infections inSoft Tissue
Sarcomas Resection
Surgical Site Infection (SSI) in soft tissue sarcoma resection is more common in junctional
areas, like the groin and the axilla [30], and when
the reconstruction is with a cutaneous-fascial
ap. It is pivotal for optimal reconstruction after
STS resection multidisciplinary teamwork with
Plastic Surgery [31] in the so-called Ortho-plastic
approach [32].
SSI in soft tissue sarcoma resection is not a
rare complication, the rate of SSI ranges
between 8.3% [33] and 43.3% [34]; the highest
rate was found in resection of STS of the pelvis
[35]. It was found a trend of higher rates of SSI
in immediate reconstruction and in patients
who underwent neoadjuvant radiation, without
28 Infections inOrthopedic Oncology
405
being statistically signicant in some series
[34]. A wider series showed that a higher incidence of SSI was signicantly correlated with
tumor dimensions >5 cm and preoperative
XRT [36].
SSI was shown to be an independent risk factor for the length of hospitalization [33].
Furthermore, patients with SSI after STS resection had higher local recurrence rates, lower survival, and worse oncological outcomes [33].
Because SSI can delay or prevent other crucial
therapies for local and systemic control, in 13%
of patients an SSI delayed post-operative XRT
and CHT while 8% of patients did not receive
any XRT due to SSI [36].
Among the consequences of SSI, there were
repeated uid collections aspirations and prolonged need of dressing of the wound [37], and in
the same series, 18% of patients required a surgi-
cal revision for SSI [37]. In a recent series, wound
dehiscence and SSI were the most frequent complications after STS surgery (as high as 34%)
[38]. In short-term follow-up of STS resection,
acute wound complications were the rst complication, while the long-term complications were
chronic radiation-related limb complications,
part of them SSI.It is interesting to note that XRT
complications in STS resection show a higher
rate for tumors located in the groin area and are
related to acute wound complications [36],
(Fig.28.2).
Smoke was signicantly associated with
major complications after STS resection, while
obesity and bone exposure after resection showed
a trend of association with SSI, that was not statistically signicant [37]. Multiple other risk factors for SSI were investigated without highlighting
strong statistical signicance [33].
ab
cd
Fig. 28.2 (a) Surgical Site Infection in a 64years old female patient after pre-operative XRT and resection of a thigh
high-grade liposarcoma, (b, c) debridement of necrotic tissues and irrigation, (d) wound closure
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28.2.2 Infections inResection
of‘Expendable’ Bones Without
Reconstruction
Surgical site infection (SSI) after resection of
expendable bones is a difcult topic, few bones
are considered really expendables and not worth
reconstruction, but the scapula and bula are
among the sites where is still debated the possibility of reconstruction and what there are data on
SSI rate.
SSI in scapular resections can occur when
there are large soft tissue defects, and an adequate
reconstruction is not possible. In scapular resection, the SSI reported rate varies between 3%
[39] and 9% [40]. The cases are deep SSI postscapulectomy in a patient with radiation-induced
osteosarcoma and supercial SSI postscapulectomies, wound complications successfully treated with a course of antibiotics [39, 40].
This rate of SSI is comparable to the SSI rate in
other resections around the shoulder joint,
between 0% and 5.4% [41–43].
Prosthetic reconstruction of the scapula shows
a better function but a higher SSI rate, due to the
more difcult soft tissue coverage and the presence of hardware [44]. As shown by a series of
prosthetic reconstructions of the humeralscapular joint, with partial resection of the scapula, where the rate of patients that required
hardware removal for SSI was 25% [45].
A possible option of reconstruction without
endoprosthesis is a humeral suspension (using
remaining rotator cuff tendons), in this case of
soft tissue-only reconstruction the SSI rate was
4% to 9% [46], patients treated successfully with
antibiotic therapy, 1 patient of a series required
reoperation with debridement and subsequent
targeted antibiotic therapy [44].
In the bula resection for bone tumors, the SSI
rate widely varies between 9% and 17.5% [47,
48]. Due to the limited number of patients in the
series, the different entities of the resection, and
the different sites of the resection (proximal,
intercalary, and distal) have to be carefully taken
into consideration, together with the denition of
SSI.When considering SSI as a deep infection
the distal bula resection seems to have a higher
risk of SSI, while considering the wound healing
problems as SSI, the proximal bula resection
bears the highest rate of wound complications
[47, 48].
Neoadjuvant and adjuvant chemo/radiation
therapy can lead to a higher rate of SSI, the rate
of SSI is higher also with the use of grafts for the
reconstruction of the resected bula [49, 50].
Autografts are less affected by SSI compared to
allografts [51]. Good soft tissue coverage is pivotal to reducing the dead space around the reconstruction (or the cavity left by the resection),
reducing the SSI rate in bula resection [52].
28.3 Infections inResection
withReconstruction
This paragraph discusses the Surgical Site
Infection (SSI) in resections for bone tumors followed by reconstruction without an endoprosthesis, meaning SSI after allograft reconstruction.
SSI in allograft reconstruction varies between
11.9% and 13.5% [53] in the extremities, reaching 50% in pelvic allograft reconstruction, the
last topic is treated in another paragraph of this
chapter. The overall free survival from infection
for allograft reconstruction at 5 years is 92%
[53]. In the extremities, the proximal tibia has a
higher risk of SSI after an allograft reconstruction, with up to 15% of deep infection and 48%
of soft tissue complications [54].
The high incidence of SSI in allograft reconstruction was associated with the characteristics
of the allograft itself, being non-vital bone (acellular and avascular) and with high porosity, being
a very favorable environment for bacterial infection [55]. Bacteria, once seeded on an allograft,
easily form a glycocalyx matrix (biolm) preventing immune response ed. effectiveness of
antibiotics [56].
Multiple risk factors analyzed show a statistically signicant inuence on the rate of SSI in
allograft reconstruction. Tibia allografts, male
sex, and longer post-operative antibiotic prophylaxis are associated with a higher SSI rate [53].
There is a reported higher rate of SSI in patients
with allograft reconstruction who received high