The infected implant.

In summary, I believe that when faced with a definitely diagnosed deep infection involving a joint replacement of the foot, the treatment of choice is incision and drainage of the wound with removal of the implant and all necrotic bone and soft tissue. Postoperatively, some form of drainage-promoting system should be instituted. Three techniques for promoting drainage have been discussed: open packing, which technically is the easiest to accomplish, but necessitates either delayed primary closure, healing by secondary intention, or in some cases skin grafting; this obviously increases disability time; standard closed suction irrigation, which has the advantage of primary wound closure but the disadvantage of requiring around-the-clock supervision to ensure against blockage of fluid flow, especially through the egress tube; and the Sorto modification of the one-tube in-out drainage system, which has the same advantage as closed suction irrigation (primary wound closure) without the risk of blockage of the egress tube. The key to successful management of an infected implant is immediate and aggressive treatment once a definitive diagnosis is made. Although the systemic use of antibiotics is an important adjunct in the total treatment plan, one must think in terms of altering the local environment in which the offending organisms grow and multiply. This is best accomplished by decompressing the infected wound by incision and drainage; removing all necrotic tissue or foreign bodies (that is, implants); and continuously promoting drainage postoperatively. Parenteral antibodies are only effective if the blood system through which they travel reaches the local site of infection. This cannot readily occur in the presence of increased soft-tissue tension created by an infectious process. In the words of Louis Pasteur, when dealing with an infection, "The bacteria is nothing, it is the environment in which it grows that is everything."