Recently there have been many studies on the prevention of SSIs. These include studies on the administration of preoperative antimicrobial agents timed such that serum and tissue concentrations are established at the start of surgery, the implementation of glycemic control in diabetic patients to ensure perioperative blood glucose levels are <200 mg/dL [2], the maintenance of perioperative normothermia [43], and the administration of a higher fraction of inspired oxygen (FiO2) both intraoperatively and in the immediate postoperative period [44]. The findings of these studies have been incorporated into guidelines on the prevention of SSIs by the CDC and others. In general, I believe that most of these findings are relevant to infections in osteosarcoma patients. However, in some aspects, there must be differences in the pathophysiological conditions of SSI establishment between conventional orthopedic surgery and surgery for orthopedic malignancy. This is discussed in the next section.

The most obvious risk for infection in osteosarcoma patients is the lack of soft tissue resulting from the wide margin used in tumor resection, and there is a large amount of evidence directly or indirectly suggesting the significance of soft tissue preservation in the management of infection. A study by Grimer et al. in 1999 on the management of proximal tibia osteosarcoma showed an infection rate of 12 % and 36 %, respectively, in cases with and without a gastrocnemius flap [32]. In a study of SSI following proximal tibia reconstruction with prosthesis due to malignancy, patients with gastrocnemius muscle flap coverage at initial surgery needed significantly fewer surgical procedures to control subsequent infection than those without a flap [6]. Thus, the routine application of a muscle flap, both with prosthetic and biological reconstruction, is currently recommended for infection control (Fig. 12.4) [10]. Likewise, in a previous study, I have shown that extended resection of the quadriceps in distal femur cases increased the risk for deep infection following prosthetic reconstruction [1]. Patients with extracompartmental resection tend to lose more soft tissue, as a larger margin is resected with the tumor. In infected patients, the final infection control rate is better for intracompartmental rather than extracompartmental resection [6]. Moreover, the risk of amputation is elevated with extracompartmental resection [6]. Although the preservation of soft tissue is practically dependent on the tumor extension, I would refer to the routine use of gastrocnemius muscle flap coverage in proximal tibia cases. In addition, if extended resection of soft tissue is required and a severe lack of soft tissue is expected due to surgery at another site, plastic surgery should be considered at the initial surgery for soft tissue coverage.

These findings highlight the differences in surgical conditions between oncological resection for osteosarcoma and conventional orthopedic surgery. A recent study on SSI in orthopedic surgery recommends a shorter period of single antimicrobial prophylaxis to prevent the emergence of antibiotic-resistant bacterial infection [45]. So far, there have been few studies of antimicrobial prophylaxis modality in orthopedic oncology. In 2013, Racano et al. conducted a systematic review of articles published in English between 1980 and July 2011 on clinical studies of infection rates in adults with primary bony malignancies of the lower extremities that were treated with surgery and endoprosthetic reconstruction. The pooled weighted infection rate was 13 % after short-term (<24 h) postoperative antibiotic administration and 8 % after long-term (>24 h) postoperative antibiotic administration [9], suggesting that long-term antibiotic prophylaxis reduces the risk of deep infection. Likewise, a considerably lower rate of postoperative infection with long-term antibiotic administration has been recently reported [46]. In addition, others and I have found that the use of one instead of two antibiotics during orthopedic oncological resection and endoprosthetic reconstruction surgery conferred a significant risk of amputation [6]. This shows that the prevention of SSI during conventional procedures is not always applicable to SSI in osteosarcoma surgery. Although the low case number and heterogeneity in terms of tumor location, surgery duration, tumor size, and reconstruction modality, in addition to immunological suppression in patients would make it difficult, concrete guidelines on the prevention of SSI in orthopedic oncology should be established.

Antibiotic administration is easy to perform and less invasive and is used in the management of most SSIs in the early stages of disease. As mentioned above, infection control with antibiotics alone occurs for <10 % cases with both endoprosthetic [4] and biological reconstruction (Table 12.2) [10, 12–14, 19, 47–49]; however, for both patients and surgeons, this is the best option. Thus, I analyzed the properties of cases from a previous study with tumor-associated endoprosthetic reconstruction around the knee, in which conservative therapy was effective in SSI control, and found that conservative therapy was significantly more successful in cases with prostheses in the tibia than the femur and more successful in cases without discharge/pus at infection presentation [6]. In addition, Hardes et al. reviewed 30 such patients and found that only one patient with a late, low-grade infection could be treated successfully with intravenous antibiotics [5]. In biological reconstruction, surface infection is more successfully controlled by conservative therapy [14, 47].