A Patient's Guide to Bone Infection Surgery

This page is for people who have been given a diagnosis of bone infection and would like to know more about what this means and what the treatment options are.

You may have questions that are not answered by the information written here. There is more detailed information in appendix A and you also  will find other sources of information. You wil also find a list of people you may contact to find out more.

Your cooperation is essential to the success of your treatment. We will give you advice on how to optimise your lifestyle to have the best chance of a good outcome. We will also provide advice on how to manage your condition.

A bone infection is an infection inside a bone. If the infection is of the bone and bone marrow it may also be called osteomyelitis. If the infection occurs after a fracture (a break in the bone) treated with or without surgery, then this is called a fracture related infection (FRI).

Symptoms include increased pain, warmth, redness and swelling. An open wound called a sinus may develop. You may also have a fever, chills or night sweats.

A joint infection is infection inside a joint such as a knee, hip or shoulder. If the infection occurs in a native joint (ie with no prosthetic joint) then this is known as septic arthritis. If the infection is in a joint with a prosthesis (a joint replacement) then this is called periprosthetic joint infection (PJI).

This can lead to the joint becoming swollen, red, warm and painful. The joint may be very difficult to move. You may be very unwell.

Infections can reach a bone by travelling through the bloodstream or spreading from nearby tissue.

They can arise due to a previous injury or fracture or an infection elsewhere in the body (such as a tooth infection or urinary tract infection) but sometimes the cause is not known.

Bone infections may occur in patients with weaker immune systems such as those taking steroid treatment, chemotherapy or patients with diabetes.

Bone infections may involve different parts of the bone and the treatment options depend on the area of bone involved.

The classification of bone infections can help guide treatment options and also helps to understand how successful treatment will be. Two classification systems are used by the team at the RNOH, detailed in Appendix A, below.

There will be multiple specialties and members of staff involved in your care. We call this the multidisciplinary team (MDT).

The limb reconstruction team includes:
• Orthopaedic surgeons
• Limb reconstruction nurse specialists
• Specialist physiotherapists

The plastic surgery team includes:
• Plastic surgeons
• Tissue viability Clinical Nurse Specialists (TVN)

The microbiology team includes:
• Microbiology doctors
• Infectious diseases doctors
• Specialist nurses
• Outpatient, Parental Antibiotic Therapy (OPAT) nurses

The treatment of bone infection is usually surgical which aims to fully remove all the infection.

Alternative techniques may also be considered for example if you are too unwell to undergo surgery or if you feel that the surgical treatment is worse than living with the disease. Many patients can live with bone infection for many years with limited symptoms and only occasional flare-ups. If a decision is made to not undertake surgery, then the symptoms may be managed with medication, physiotherapy and lifestyle changes.

The following surgical treatment principles apply to most cases of bone infection:
• Meticulous sampling to send specimens for microbiology and histology analysis
• Local antibiotic delivery
• Removal of infected and dead bone and soft tissue
• Thorough irrigation
• Bone stabilisation with an external fixator if needed (further information about having about having an external fixator can be found in the patient leaflet)
• Good soft tissue cover
• Broad spectrum antibiotics until microbiology results are known
• Targeted antibiotic treatment once results are known.

You will usually receive a general anaesthetic for your procedure. You may also receive a lower limb nerve block. Your anaesthetist will discuss these options with you before surgery.

The affected limb will be cleaned and an incision made to access the affected bone. Bone and soft tissue samples will be taken and sent to the lab for microbiology and histology analysis.

The aim is to remove infected/dead bone and soft tissue. This is called debridement.

Once we are confident that all affected tissue has been removed, the area will be thoroughly irrigated with saline.

A local antibiotic may be inserted into the bone.

If there is sufficient stability for you to walk, then nothing further will be done with the bone. If there is a break in the bone, or a risk that the bone will break when you walk on it, then an external fixator may be applied to the limb.

If it is possible to close the wound with good tissue over the area, then dissolvable stitches will be used. If it is necessary to plan for a more complex closure of the wound, then this will be done with the plastic surgeons.

If a wound is difficult to close, or if soft tissue cover needs to be improved to treat the infection, then a flap may be recommended. The type of flap recommended depends on the size of the defect and the location. It may include rotational flaps or free flaps or a skin graft.

Antibiotics may be put directly into the bone at the time of surgery. This is sometimes called ‘local antibiotic delivery’ or ‘intra-focal antibiotics’. Products commonly in use include: Stimulan, Osteoset and Cerament. These may be called ‘antibiotic carriers’.

You may also need to take antibiotics through a drip in your arm (intravenous or IV antibiotics) and/or oral antibiotics (usually as a tablet). This may be called ‘systemic antibiotics’. You will usually be given a dose of antibiotics in the operating theatre and these IV antibiotics will continue for 24 to 48 hours after surgery.

When results are available from the microbiology laboratory, the IV antibiotics may be converted to oral antibiotics or stopped all together.

This depends on the type of infection you have, the severity and your general health. The decision will be made by the MDT with the advice particularly of the microbiologists and surgeons.

Most patients will initially be on intravenous antibiotics and then a 6 week course of oral antibiotics. If there is no suitable oral antibiotic, you may need to be on IV antibiotics for a prolonged period but this can be done on an outpatient basis or at home.

Some patients may have an allergy to the antibiotic that is chosen for treatment. If this is the case, there is usually an alternative that can be used.

If you are known to have any allergies, particularly to any antibiotics, please let the team know.

Severe side effects are rare. Common milder side effects include:
• Nausea
• Reflux

The page ‘A Patient’s Guide to OPAT’ and ‘A Patient’s Guide to Oral Antibiotics’ provides more information about this.

We are not currently recruiting to any bone infection trials at the RNOH.

Don’t smoke or vape
We strongly advise that you do not smoke or spend any time in a smoky environment. Nicotine is known to delay bone healing and increase the risk of complications. There are many options available to help you quit. We also recommend that you avoid vaping as this contains nicotine.

Your G.P will be able to give you advice or you can contact your local NHS Stop Smoking service for advice, help and support: Go to www. nhs.uk/smokefree. See patient information guide on our website: Stop before your op. Please be aware that the RNOH has adopted a no smoking policy. Patients or visitors are requested not to smoke or use electronic cigarettes (e-cigarettes) in the hospital buildings or grounds.

Eat well
Although you may feel less hungry, it is important to eat well. Make sure you include at least one of the ingredients listed below in each meal to help bone and wound healing.
• Protein (found in meat, fish, cheese, eggs, milk, tofu, nuts and seeds)
• Calcium (milk, cheese, cereals and green vegetables)
• Vitamin C (fruit, fruit juices and green vegetables)
• Vitamin D (margarine, fish and fish liver oils)

Please be aware that some painkillers and restricted mobility can cause constipation. In order to relieve the symptoms of constipation try to drink plenty of water and eat food that contains fibre such as wholemeal cereal, wholemeal bread, fruit and vegetables.

Take Vitamin D supplements
Many people in the UK are deficient in vitamin D, particularly during the winter months. Your vitamin D level will be checked as part of your assessment, but we recommend you eat a well-balanced diet and enjoy being outdoors (with appropriate sun protection) where possible.

Sleep well
Sleeping can be difficult at the beginning, but you will find the most comfortable position. We normally recommend placing a pillow between your legs, or arm and trunk.

Stay active
It is important that you remain as active as possible and continue to move to avoid any muscle atrophy and provide good blood flow to the healing bone and tissues. It is also important to keep moving your joints so that they do not become stiff. Do little amounts of activity often and ask for help if you need it.

Bone requires weight bearing in order to heal. If you have been encouraged to weight bear, it is important that you do this so that the bone heals.

Look after your mental wellbeing
Going into hospital is stressful and it is not unusual for patients undergoing prolonged treatment to experience varying degrees of emotional turmoil. Undergoing treatment for a bone infection may be the culmination of many years of treatment and there will be times when you feel it will never end. Reduced mobility will curtail your social life and you will be more dependent on others for your daily needs. Some patients find the appearance of their limb, or the discharge from wounds unpleasant and you may find people’s reactions to this upsetting. Not everyone suffers emotional problems but you should be aware that this could occur and seek advice from your nurse or doctor if you feel you need extra support.

You will receive analgesia (pain killers) whilst you are on the ward. You will be given advice about pain killers to take on discharge.

There are some pain killers that you should avoid as they are thought to interfere with the process of bone healing. These are Non-Steroidal Antiinflammatory Drugs (NSAIDS). NSAIDS include Diclofenac, Ibuprofen, Ketoprofen, Naproxen, Fluribiprofen, Indomethacin, Mefanamic Acid, Piroxicam. Please note that this is not an exclusive list and that these are generic names and commercial names may be different. Ask your chemist/nurse/GP for help if you are unsure.

Your wound will be fully dressed in theatre and usually checked on post operative day 2 while on the ward and prior to discharge. If you have a flap, the plastics team will follow a protocol for dressings.

If your wound has been closed, this will usually be done with dissolvable sutures. You should keep the dressing clean and dry until the dressing is no longer needed. We usually advise the wound is covered for at least the first two weeks. We will then let you know when the dressing is no longer needed at your first outpatient appointment, which will usually be within 2 weeks of your surgery date.

Some local antibiotics can create a discharge from the wound. This usually looks like toothpaste. This is not a cause for concern and usually dries up without any intervention. The dressings may need to be changed more frequently if there is wound ooze. If you are concerned about this, please ask someone from the team.

If you have any concerns about your wound after you have been discharged, please contact the team, our contact details can be found at the back of the leaflet Please do not change your antibiotic regimen or start new antibiotics without first discussing with us.

You may be able to return to work quite quickly after going home but this depends on:

• what your job entails
• how you plan to get to work
• if you have an external fixator in place
• how you feel
• if you require regular dressing changes
• if you are on oral or IV antibiotics

Explain your situation to your employer and check whether they can make special arrangements if you need them. We are happy to help if your employer would like more information. A Fit Note can also be completed by your surgeon stating any special requirements such as the need to keep your limb elevated, or attend regular physiotherapy sessions.

Joint stiffness and soft tissue tightness can be a problem and may affect your ability to mobilise. It is of prime importance that you perform the exercises that the Physiotherapists provide, or wear any necessary splints as instructed.

Are there any complications related to surgery?
Rarely nerves and blood vessels can become damaged. This can be either at the time of surgery or during the subsequent lengthening or repositioning of the bone. You should inform nursing and/ or medical staff if you experience pain, numbness or pins and needles.

Acute Compartment Syndrome
Acute Compartment Syndrome is a painful condition that occurs when swelling or bleeding causes increased pressure within the muscle compartments. It will usually be diagnosed and treated when you are already in hospital, however, it can occur several days after surgery. The main symptoms are:​​​​​​​
• Severe pain which is constant. The pain may worsen upon movement
• when the muscles are stretched.
• Tingling or burning sensation in the area.
• The skin in the affected area may become pale, cold, tense and hard
• Reduced strength and movement in the affected area

Acute compartment syndrome is a medical emergency. If you experience any of these signs or symptoms, you should inform a member of your consultant’s team or attend your local accident and emergency department immediately. Further information about Acute Compartment Syndrome can be found in the booklet: ‘A patients’ guide to Acute Compartment Syndrome’

Deep Vein Thrombosis (DVT)​​​​​​​
There is a risk of developing a DVT. This is a blood clot which is treated by medication that thins the blood. Your risk factors for this occurring will be assessed by medical staff and if necessary you will be placed on anticoagulation therapy.​​​​​​​

Pressure Ulcers
A pressure ulcer is damage to the skin and underlying tissue. They can be caused by pressure, shear or friction. Pressure ulcers tend to form where bone causes the greatest force on the skin. This is caused when the body is in contact with the mattress, chair or another part of the body. Areas such as the bottom, heel, hip, elbow, ankle, shoulder, back and the back of the head are vulnerable.​​​​​​​

You should always elevate your limb and ensure the clips holding the dressings in place are not tight or digging into your skin

Further information can be found in the page: ‘A patients’ guide to pressure ulcer prevention’

Delayed union/ non union
This may occur if the bone does not form after surgery or takes a long time to mature. This may occur due to biological factors (such as the presence of nicotine or low vitamin D, or presence of infection) or mechanical factors (such as not putting weight through the limb or the fixation not being strong enough). Your consultant will advise you about treatments should this arise.​​​​​​​

Fracture
Following debridement of a bone, the bone may be weak and fracture. If the bone is at risk of this at the time of surgery, you will have an external fixator applied or be asked to walk with the support of crutches until the bone heals. If the fracture occurs after surgery, you may require further surgery.​​​​​​​

Recurrence
Even with excellent surgical and antibiotic treatment, there is a risk that the infection recurs. By following advice, you will be doing the best you can to minimise this risk.​​​​​​​

The worst-case scenario is that if there was an uncontrolled infection, damage to the arteries and nerves or interruption of the blood supply to the muscles, there is a risk that this could lead to amputation of the limb.

You will be cared for by the MDT. A common pathway is shown here. Each pathway is tailored to the individual patient.  

You will have a bone infection & OPAT telephone clinic every week whilst on intravenous antibiotics or every 2 weeks whilst on oral antibiotics.

All in-patient care takes place at the Stanmore site.

Out-patient visits may be either at the Stanmore site or in central London at Bolsover Street. It is important that you check the location of any clinic appointments.

You are likely to be in hospital for approximately 4-6 days after surgery. During this time you will receive adequate pain relief, antibiotics and a definitive antibiotic therapy plan will be made. You will be reviewed by both the orthopaedic and microbiology teams. If you have had a plastics procedure, you will also be reviewed by the plastics team.

You will also receive physiotherapy input whilst on the ward. The exercises given to you by the physiotherapists are extremely important and will aid you to mobilise and help prevent complications associated with treatment. If appropriate, you may also be reviewed by the Occupational Therapist.

You will normally be admitted to the RNOH on the day of your operation. Full details about coming into hospital will be given at your pre-operative assessment clinic appointment.

We will aim to discharge you before 11am. Please ensure that your family member / carer is aware to collect you before this time.

The doctors will have told you when they wish to review you in clinic. The most common time is 2 weeks after the operation, although this can vary for individual patients. If it is possible to make you an appointment before you go home the nurses will inform you of the date, time and venue (your outpatient review may be at either Stanmore or Bolsover Street). If this is not possible, an appointment will be sent to you at home.

The outpatient review may take several hours as you will have x-rays, see the Surgeon and also have a pin site/wound review from the nurses. If you have an external fixator you may also need adjustments to be made to the frame.

Detailed maps of each hospital site as well as advice on public transport and parking can be found on the hospital website: www.rnoh.nhs.uk/ find-us

If you are travelling by car, you may find it easier to sit in the front seat with the seat pushed back, cushions can be used to support your leg.

Certain medicines may affect your ability to drive. It is an offence to drive while your ability is impaired. From 2nd March 2015 a new law was introduced stating that it is an offence to drive with certain drugs above specified blood levels in the body. This includes strong painkillers such as morphine or opiate based medications such as Codeine, Tramadol and Fentanyl. If you are stopped by the police and have taken prescription medication you will need to demonstrate you have been prescribed it for a medical problem and that you took the medicine according to the instructions given by the prescriber.

For more information go to: www.gov.uk/drug-driving-law

When booking an appointment or an admission at the Royal National Orthopaedic Hospital’s (RNOH) Stanmore site or an appointment at the RNOH’s Bolsover Street site, it is your responsibility to make your own way to and from the hospital. If you require transport for medical need only, you will need to contact the transport assessment team for a confidential assessment at least 48hrs before your appointment. You will be screened using a set of questions to establish your mobility and potential for specialist care on the journey.

Please call the transport assessment team Monday-Friday between 09.00 and 17.00 on 0800 953 4138 (the office is not open on bank holidays)

If you would like further details regarding hospital transport, please ask for a copy of: “A guide to Patient Transport services”

Contact numbers

Hospital switchboard: 020 3947 0100
Outpatient appointments: 020 3947 0046 Option 2
Miss Tissingh Secretary: 020 8909 5890
Limb reconstruction nurse specialist: 020 8385 3012
OPAT Microbiology nurse specialists: 020 8385 3046
Physiotherapy outpatients: 020 8909 5820

Contact emails

OPAT Microbiology nurse specialists
rnoh.boneinfection@nhs.net​​​​​​​

Limb Reconstruction nurse specialists
rnoh.limbreconstruction@nhs.net

Tissue Viability clinical nurse specialists
rnoh.tissueviability@nhs.net

In the event that you are unable to contact a member of the limb reconstruction team and feel that you have an urgent problem, you should visit your GP or local emergency department for advice.​​​​​​​

Please note that this is an advisory page only. Your experiences may differ from those described.​​​​​​​

Two classification systems are used by the team at the RNOH, these are the Cierny and Mader classification and J S BACH.

The Cierny and Mader classification is divided into two sections: anatomic (the site of the infection) and the host (the type of patient who has the infection).

CM Anatomic
Stage 1:Medullary
Stage 2:Superficial
Stage 3:Localized
Stage 4: Diffuse

Physiologic change
A host: Normal host
B host: Systemic compromise, Local compromise
C host: Treatment worse than the disease

Medullary and superficial lesions are limited to the inner and outer surfaces of the bone, respectively. When full-thickness sequestra are present, treatment and prognosis depend on the stability (localised) or instability (diffuse) of the skeletal segment.

The JS BACH classification categorises cases as Uncomplicated, Complex or Limited Options. This is illustrated in the following table: