are presented in manuscript body than in the abstract.
3. Carefully pay attention to figures and tables (some journals require that all results be presented in table and figure form in addition to prose).
D. Introduction and discussion
1. These sections are potentially more beneficial for the novice reader.
2. Often set the context for the research question and can provide context for use of the results in the scheme of current practice.
3. These sections often represent authors’ opinions and are potentially least helpful to the intermediate/expert reader.
E. References
1. Pay attention to references from reputable journals.
a. A foreign journal is not disreputable.
b. Some open-access journals are very respectable.
2. If many references are from textbooks, be wary.
a. Textbooks/review articles may quote literature incorrectly.
b. A reference to a textbook or review article which misquotes the literature is misleading (perhaps unintentionally).
c. Always go back to source literature (primary research articles), when possible.
Suggested Readings
Greenhalgh T. How to Read a Paper. 5th ed. Wiley Blackwell and BMJ Books, West Sussex, United Kingdom; 2014
JBJS Inc. Levels of Evidence, https://journals.lww.com/jbjsjournal/Pages/Journals-Level-of-Evidence.aspx. Accessed January 17, 2018
Kirkwood BR, Sterne JAC. Essential medical statistics, 2nd ed. Blackwell Science Ltd, Oxford, United Kingdom; 2003
6 Acute Infection Following Musculoskeletal Surgery
Frank R. Avilucea and William T. Obremskey
Introduction
Postoperative infection following internal fixation involves the soft tissues (skin, subcutaneous tissues, muscle fascia, and muscle), hardware, and potentially the bone. The infection is typically bacterial (▶Video 6.1).
I. Preoperative
A. History and physical exam
1. Presentation:
a. Purulent discharge from the surgical site and/or incision with or without associated erythema, tenderness, or fever.
b. Symptoms (local or regional pain or joint stiffness) which may be less obvious signs of infection.
c. Absence of radiologic evidence of bone healing after several months, with or without fixation failure, may also suggest infection.
d. Intermittent fevers, chills, sweats (particularly, night sweats in the setting of chronic infections), and general malaise are common symptoms.
e. An untreated infection may progress rapidly and threaten the limb, lead to septic shock, or even lead to death.
2. Physical exam findings at the surgical site:
a. Pain.
b. Erythema or overlying cellulitis (▶Fig. 6.1).
c. Drainage.
d. External appearance may be benign with deep space infection.
3. Host risk factors for developing infection:
a. Diabetes mellitus.
i. Perioperative hyperglycemia.
ii. Micro- and macrovascular disease.
iii. Immunologic dysfunction.
b. Peripheral vascular disease.
c. Malnutrition.
Fig. 6.1 Clinical photos demonstrating varied clinical presentation of deep infection (a, b). High suspicion is necessary for post-operative surgical sites with atypical findings or patient reporting increased pain.
d. Obesity.
e. Advanced age.
f. Immunocompromised (HIV).
g. Immunomodulating drugs:
i. Steroid treatment.
ii. Chemotherapy (cancer treatment).
iii. Disease-modifying anti-rheumatic drugs (DMARDs) for autoimmune disorders.
h. Polytrauma.
II. Anatomy of Infection
A. Superficial surgical site infection
1. Early fracture site colonization and proliferation.
2. Affects the incision but does not extend to the fracture site and remains superficial to the level of the fascia.
B. Deep surgical site infection
1. Infection that penetrates deep to fascia and involves the fracture site.
2. Surgical devices represent a substrate for microbial colonization and biofilm-associated infection.
a. Variety of organisms have been associated with indwelling implants, some of the most common are:
i. Staphylococcus (aureus, epidermidis).
ii. Streptococcus pyogenes.
iii. Klebsiella pneumoniae.
iv. Pseudomonas aeruginosa.
v. Acinetobacter baumannii.
vi. Escherichia coli.
3. Pathogenesis of biofilm includes following four stages (▶Fig. 6.2):
a. Planktonic—free-floating which represents the inoculation phase.
b. Sessile phase: bacteria settle
