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Since the past mid-century, surgeons have started to look at the advantages of a local application of anti-infective substances aiming at a better infection prophylaxis and/or eradication of an already established infection in organs or tissues which are generally »difficult to access« for systemic antibiotics (AB).

Open fractures are commonly associated with additional major injury following high-energy mechanisms. A thorough evaluation of the local injury as well as considering the patient’s status represents the basis for therapeutic steps. further Careful debridement and irrigation using pressure pulsatile lavage should be performed within the first 12 h. Systemic antibiotic administration should be performed as early as possible for infection prevention. Dependent on the patient’s condition and local injury pattern, fracture stabilization should be performed with external or internal stabilization devices. For type I and II injuries primary wound closure is possible, in type III injuries temporary wound closure using negative-pressure wound therapy should be performed.

Acne is the most common dermatologic disease and manifests with different clinical presentations and in varying ages, but mostly at about 70–95 % of all young people aged 15–18 years [1]. Acne lesions occur especially on the face and upper trunk. In the majority of patients acne regresses spontaneously after puberty. In 10 % of cases, however, the disease persists over the 25th year of age. Acne can be classified according to the clinical picture, the age of onset, and its severity (Table 51.1).

In orthopaedic implant surgery, infection is rare but devastating for the patient and costly for society. With improved surgical techniques, stricter pre- and perioperative routines and antibiotic prophylaxis, the infection rate after primary total hip arthroplasty (THA) has been reduced from 5–10% in the late 1960s to around 1% today (Lidgren 2001; Lidgren et al. 2003; Zimmerli et al. 2004). In previous papers based on the Norwegian Arthroplasty Register, a lower revision rate of primary THAs was found when antibiotic prophylaxis was given both systemically and in the bone cement compared to systemically only, in bone cement only, or compared to no antibiotic prophylaxis at all (Espehaug et al. 1997; Engesaeter et al. 2006). The importance of systemic antibiotic prophylaxis in primary THA surgery seems to be well accepted; however, the benefits of antibiotic prophylaxis in bone cement remain in question (van de Belt et al. 2001).

Infection rate following implatation of an orthopedic device has continuously decreased during the last 50 years [4] but, since the numbers of trauma and aged patients requiring joint replacement is steadily increasing, the absolute number of patients with device-associated infection is raising [10]. The infection rate should not exceed 1% in patients with primary hip replacement and 2% in those with knee replacement [6, 7, 14]. However, the real overall risk per patient-life is unknown, since in most case series only the first 2 years after implantation are considered.

At the beginning of the nineties visiting the operation theatres, it was possible to see the surgeons modelling with their hands bone cement in order to obtain handmade devices with a prosthesis-like geometry. The device was created to replace temporarily the removed septic prosthesis. The positioning in the septic site of an antibiotic-loaded bone cement device aimed at strengthening the systemic antibiotic therapy. As a matter of fact systemic antibiotic therapy is not always able to guarantee optimal antibiotic concentration in the infected site. After some months from implantation, the device was removed replacing it with a new prosthesis, giving back to the patient an healed joint and a certain functional recovery. This devices were called “spacers” [1, 7, 13, 14].

We have known for some time from the work of Professor H.W. Buchholz in Hamburg, Germany and his coworkers that gentamicin-containing bone cement has a prophylactic effect against postoperative infections in total joint replacement surgery (Buchholz and Engelbrecht, 1970; Rottger et al, 1979). It is not possible, however, to draw definite conclusions about the prophylactic effect of gentamicin-containing cement based on the above mentioned investigations since they were not controlled. Therefore, to investigate the prophylactic effects of the gentamicin-containing cement in greater detail, a large-scale study was started in Sweden in 1976 (Josefsson et al, 1981). This study was undertaken by the Departments of Orthopaedic Surgery at nine Swedish hospitals to enlarge the patient population sufficiently for an evaluable assessment. It was a prospective, controlled study, completed in 1979. The purpose of this investigation was to compare the generally accepted prophylactic effect of systemic antibiotics with gentamicin cement whose prophylactic effects were, at that time, somewhat questionable.

It is redundant to affirm that for orthopedic operations, especially total joint replacements, clean air is a mandatory requirement. The problem of wound pollution, however, has not yet been solved. I remember conversations with Sir John Charnley in which he expressed optimism that one day we would be able to pursue long surgical procedures with complete confidence that infection would never occur. However, even in one of his early papers (Charnley and Dandy, 1974) it was clear that despite a marked fall in the incidence of deep infection to 0.5%, superficial infection continued to occur in 7% of patients -- a serious and worrisome problem. At that time, many bacteriologists and surgeons remained sceptical as to the need for clean air and to the contention that so-called “nonpathogenic” organisms were significant; the succeeding ten years have amply substantiated both points. The problem of superficial infection remains, however, with its potential to cause more serious deep infection. As bacteriologists have become more aware of the pathogenicity of low grade organisms, we are in a better position to take the final steps of overcoming the problem.

Orthopedic surgeons dread the complications of chronic osteomyelitis. Infection in bone can persist, despite thorough debridement, sequestrectomy, saucerization, and long-term systemic antibiotic therapy.

Evaluation of short-term parenteral antibiotic prophylaxis used as a supplement to selective decontamination of the digestive tract (SDD) presents many difficulties. This paper considers only the unspecialized medico-surgical intensive care unit (ICU), and it is accepted that a characteristic pattern of infection is recognized in units of this type. Infections described as primary are those diagnosed on admission to the ICU and up to 48 hours thereafter; they are assumed to be derived from pre-admission events. All subsequent infections diagnosed in the ICU are assumed to be unit-acquired.

In 1970, I published the early results of our total hip replacements with a minimum two year follow-up. The infection rate recorded in this paper was highly underestimated at an overall 1% in 1,352 patients (Buchholz, 1970). Subsequently, the deep infection rate rose to about 7%. During this time we were administering perioperatively systemic antibiotics. I was aware that Charnley (1969) had experienced the same problem with his hip replacements and as a result had developed the clean-air enclosure. Because of the heavy work load of general and traumatic surgery with which we had to cope, this method was not possible at our hospital and it was partly for this reason that the concept was developed of adding an antibiotic to the cement. It was recognized that any special measure to combat deep infections would be worthless unless other more general aspects of the aseptic ritual were rigidly observed. This we attempted in an average conventional operating theatre. It was our impression that hematoma formation, aggravated by the necessity to use prophylactic anticoagulation, contributed to our rising infection rate.

With the introduction of antibiotics, the mortality of brain abscesses could be decreased considerably. Since then, however, no further reduction could be achieved and the mortality in most centres ranges between 30% and 45%. In order to obtain more information concerning the factors responsible for the unfavourable prognosis and the persistently high mortality, we analyzed 73 cases with brain abscess (50 chronic, 23 acute), admitted to our hospital between 1955 and 1975.

Many patients with severe acne do not respond satisfactorily to current conventional treatment with systemic antibiotics and topical preparations usually based on benzoyl peroxide. For such patients the preliminary results of treatment of severe acne with ora113-cis-retinoic acid (3) suggested the prospect of a major advance in therapy. Later work (4) has shown that 13-cis-retinoic acid profoundly reduces sebaceous gland activity and this seems the likely mechanism of the drug’s affect in acne.

In 1977, I worked at the Endo-Klinik in Hamburg and participated in the management of many infected joint arthroplasties treated according to the principles established by Buchholz and his colleagues (1981). Inevitably, I am orientated towards a specific line of treatment but maintain an open mind as to achieving the ideal choice of therapy. At present, I am of the opinion that the basic surgical principle of excision of necrotic or inert material, the administration of systemic antibiotics, and the insertion of a local depot of antibiotics by means of antibiotic-loaded acrylic cement (ALAC) form the basis of best available treatment. My personal series of operations is summarized in Table I. Follow-up is still too short to permit a statement of definitive opinion, but as yet I have had no reason to change my choice of management. Most deep infections occur in conventionally cemented prostheses with loosening of one or both components; consequently, and especially in advanced cases, the mechanical problems associated with a damaged bone bed and loss of gross bone stock are significant. When the appearance of radiolucent zones at the bone/cement interface is alarming, I anticipate mechanical failures in the future apart from the possibilities of recrudescent infection. Nevertheless, the incidence of confirmed reinfection is low and this is the prime consideration in these patients.