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Kesavan Ramanujam

The Bacteria is nothing, the environment is everything -Louis Pasteur

Chronic Osteomylitis
Cierney Mader Classification
Medullary Superficial Localized


Chronic Osteomylitis
Cierney Mader Classification Physiological Aspects Host Normal and Healthy Host Immune compromise Local Factors Systemic Factors

1. 2.

Cierney Mader Classification

Medullary- Haematogenous Osteomylitis Superficial- Ulcer with Exposed Bone Localised- Cortex with Medullary involvement Diffuse- Cortical with Extension into medullary canal. Infected non-unions and Total joint infections with Osteomylitis included

Treatment Principles

Debridement Soft tissue coverage

Skeletal sabilisation

Treatment of bone defects

Orthopaedic infections- Special Situations

Presence of implanted device
Intra operative seeding Blood spread

Long Op time and high blood loss

Orthopaedic infections- Special Situations

Membrane surrounding the microbes


To remove or not to remove implants

Case scenarios
Infected non union difficult to treat Infection rate high in inadequately fixed fractures

Poor fixation worse than no metal

Rigid fixation can further reduce infection rate Presence of one organism can lead to other organisms colonising

Infected Joint replacements

1. 2. 3. 4. 5. 6.

Laminar Flow Pre op antibiotics Closed body exhaust suits Tissue handling Antibiotic cement Minimise traffic

Prevention better than cure

Bacterial Biofilm The glycocalyx

The culprit bacteria

Staphylococcus aureus Gram negatives including pseudomona Anaerobes



Radiographs Aspiration Bone scans Intra op frozen sections Synovial biopsy

Types of post op infection

Early post op- within 4 weeks Late chronic infection

Acute haematogenous osteomylitis

Positive intra operative culture

To retain or not Patient and disease factors

DM, Psoriasis, steroids,

immunocompromised Virulent bacteris, forming glycoclayx, gram negative bacteria, poor host bed

Single stage versus two stage revisions Gold standard is two stage revisions

Antibiotic duration Use of antibiotic impregnated cement Cement spacers

Salvage methods
Arthrodesis Resection arthroplasty Amputation Prognosis poor

1. Delayed Dx 2. Host poor 3. Poor surgical debridement 4. Virulent organism