Management of Deep Infection

, Paul D. Siney¹ and Patricia A. Fleming¹

(1)

The John Charnley Research Institute Wrightington Hospital, Wigan, Lancashire, UK

Deep infection after elective surgery is a serious complication. The problem is even more serious when a large foreign body, an implant, is an integral part of the original treatment.

In the management of deep infection after total hip arthroplasty the work of Buchholz and Colleagues has made an original and very valuable contribution: the use of antibiotic containing acrylic cement (ACAC). With time, increasing numbers of publications on the subject appeared in print. The method advocated by Buchholz and Colleagues, one stage revision, did not become readily accepted despite encouraging results. The reason is by no means clear. Was it the fear of exacerbation of the infection, the length of the operative procedure, or merely the lack of stamina on the part of the surgeon and the operating team?

One Stage Revision: The Principle [1–3]

Operative intervention in cases of infection, in any site, follows well documented principles: Removal of foreign material, if present, clearing of all infected tissues and exposing healthy deeper tissues – (as much as technically possible), application of local antiseptics/antibiotics, closure of cavities, ensuring mechanical stability, drainage of the site, rest for the patient as well as of the part involved, antibiotics. Thus the question whether the new implant is inserted has not been considered, it has been expressly implied as part of the accepted principles:

Local Antibiotics: ACAC filling the cavities thus ensuring largest possible surface area of antibiotic elution.
Closure of cavities – of the medullary canal and the acetabulum: Total hip arthroplasty components with ACAC offer not only the closure of the cavities but also stability to the site.

To reach that stage clearance of both the foreign and infected materials becomes the most demanding part of the procedure – demanding of time and detailed performance.

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