Infection
Enrique Gómez-Barrena
Infection – as distinct from mere residence of microor-
ganisms – is a condition in which pathogenic microor-
ganisms multiply and spread within the body tissues.
Microorganisms may reach the musculoskeletal tis-
sues by:
• direct introduction through the skin (a pinprick,
an injection, a stab wound, a laceration, an open
fracture or an operation, particularly when bioma-
terials are implanted),
• direct spread from a contiguous focus of infection, or
• indirect spread via the bloodstream from a distant
site such as the nose or mouth, the respiratory
tract, the bowel or the genitourinary tract.
Depending on the type of invader, the site of infection
and the host response, the result may be a pyogenic
osteomyelitis, a septic arthritis, a chronic granulo-
matous reaction (classically seen in tuberculosis of
either bone or joint), or an indolent response to a less
aggressive organism (as in low-grade periprosthetic
infections) or to an unusual organism (e.g. a fungal
infection). Soft-tissue infections range from super-
ficial wound sepsis to widespread cellulitis and life-
threatening necrotizing fasciitis. Parasitic lesions such
as hydatid disease also are considered in this chapter,
although these are infestations rather than infections.
Clinical aspects of infection will be particularly devel-
oped in this chapter. The team approach, including
microbiologists, infectious disease and internal medicine
doctors, is certainly the basis for success in infection.
However, many cases of musculoskeletal infection need
the leadership of the orthopaedic surgeon to ensure
timely diagnosis and treatment of the patient with mus-
culoskeletal symptoms and signs that suggest infection.
GENERAL ASPECTS OF INFECTION
Infection usually gives rise to an acute or chronic
inflammatory reaction, which is the body’s way of
combating the invaders by destroying them, or at least
immobilizing and confining them to a restricted area.
2
The classical signs of inflammation are frequently
present (redness, swelling, heat, pain and loss of func-
tion) and offer clinical clues about the infection and
the patient’s reaction.
Bone infection differs from soft-tissue infection
since bone consists of a collection of rigid compart-
ments. Bone is thus more susceptible than soft tissues
to vascular damage and cell death due to pressure in
acute inflammation. Unless it is rapidly suppressed,
bone infection will inevitably lead to necrosis.
Osteomyelitis is infection of bone and frequently seeds
in trabecular areas affecting both bone and bone
marrow. Soft-tissue infection depends on the main
affected tissue, but of special interest to the orthopae-
dic surgeon is joint infection or infectious arthritis,
whether septic arthritis or granulomatous arthritis.
All these forms of infection will be addressed below.
Host susceptibility to infection is increased by
(a) local factors such as trauma, scar tissue, poor cir-
culation, diminished sensibility, chronic bone or joint
disease and the presence of foreign bodies including
implants, as well as (b) systemic factors such as malnu-
trition, general illness, debility, diabetes, rheumatoid
disease, corticosteroid administration and all forms
of immunosuppression, either acquired or induced.
BOX 2.1 FACTORS PREDISPOSING TO
BONE INFECTION
Malnutrition and general debility
Diabetes mellitus
Corticosteroid administration
Immune deficiency
Immunosuppressive drugs
Venous stasis in the limb
Peripheral vascular disease
Loss of sensibility
Iatrogenic invasive measures
Trauma