Diagnosis and Management of Orthopaedic Infection after Stifle Surgery 327treated by systemic administration of an appro-
priate antibiotic. If bone consolidation or joint
stabilization has not yet been achieved, the goal
of treatment is to control the infection to pre-
vent the development of chronic osteomyelitis
until consolidation is achieved (Darouiche 2004;
Trampuz & Zimmerli 2006). More severe infec-
tions, those involving the stifle joint, or those
associated with the formation of an abscess
or wound dehiscence, require more aggressive
treatment.
Due to the devastating effect of untreated
septic arthritis, joint lavage, surgical drainage
and debridement have been recommended
over the administration of antibiotics alone for
the treatment of post-surgical septic arthritis
(Marchevsky & Read 1999). However, the
superiority of this treatment over the admin-
istration of antibiotics alone for cases that
do not involve intra-articular implants has
not been clearly demonstrated (Fitch et al.
2003; Clements et al. 2005). Lavage can be
performed using large ingress/egress needles
or through arthrotomy and joint exploration
(Marchevsky & Read 1999). The required
duration of antibiotic administration for septic
arthritis is unknown, but 4–6 weeks has been
recommended (Marchevsky & Read 1999;
Fitchet al. 2003; Clements et al. 2005). The
use of intra-articular gentamicin-impregnated
collagen sponges has been described for the
treatment of septic arthritis in the dog and
other species (Owenet al. 2004). However, this
method cannot be recommended due to the
short intra-articular elution times of the gen-
tamicin and the persistent joint inflammation
caused by the collagen sponge (Hayeset al.
2016).
Similar to other orthopaedic infections, infec-
tions associated with abscess formation, dehis-
cence or chronic osteomyelitis should be treated
with wound exploration, debridement, and
drainage (Figure 40.1). Unstable implants are
removed and, if necessary, replaced. Open
wound management with delayed closure or
negative pressure wound therapy should be
considered for dehiscence or severe infections
(Budsberg 2012; Nolffet al. 2015). The use
of local antibiotic delivery systems does not
replace the need for long-term systemic antibi-
otic administration, but can be a useful addition
to treatment (Hayeset al. 2013). In severe cases
Figure 40.1 Intraoperative picture during debridement
of a deep incisional surgical site infection after tibial
plateau leveling osteotomy surgery. Although the skin
incision was opened by the surgeon, the caudal sartorius
muscle and fascial layer have dehisced, exposing the
plate.that do not respond to traditional treatment,
intravenous regional perfusion of antibiotics
could be attempted. This procedure was first
described by Finsterbushet al. (1970) in rab-
bits with experimental septic arthritis and
osteomyelitis, and has been successfully used
in humans and horses (Finsterbushet al. 1970;
Finsterbush & Weinbergh 1972; Whithairet al.
1992; Rubio-Mart ́ınez & Cruz 2006). Regional
perfusion results in a higher synovial concentra-
tion of antibiotics than would result from intra-
venous administration alone (Whithairet al.
1992; Pilleetal. 2005). It has been associated with
low morbidity, but has not been fully investi-
gated in dogs.
Infections associated with the implant that
develop after bone consolidation are often