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Kesavan Ramanujam

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

Chronic Osteomylitis
Cierney Mader Classification
Medullary Superficial Localized

Diffuse

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

Antibiotics
Skeletal sabilisation

Treatment of bone defects

Orthopaedic infections- Special Situations


Presence of implanted device
Intra operative seeding Blood spread

Fretting
Long Op time and high blood loss

Orthopaedic infections- Special Situations

GLYCOCALYX
Membrane surrounding the microbes

DILEMMA

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

Polymicrobes

Investigations

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

Treatment
To retain or not Patient and disease factors

DM, Psoriasis, steroids,

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

Treatment..
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