Lecture 2 Bone Infections

OSTEOARTICULAROSTEOARTICULARINFECTIONSINFECTIONS

ACUTE ACUTE INFECTIONSINFECTIONS

Complex fracture – osteitis around pins

a. Complex fractures by direct trauma

1. Devitalized edges and main fragments

2. Devitalized intermediate fragments

3. Partially vital intermediate fragments (attached to periosteum)

b. Excessive drilling speed or blunt drill (thermal necrosis)

c. Pin insertion without preceding perforation (thermal necrosis, residues with necrotic fragments)

d. Preceding perforaion, correct pin placement

Osteitis following plate screws

Diaphyseal tibial fracture with extension in tibial plate; fixation by two interfragmentary screws and plate screws

Postoperative infection DUE to:

• Devitalized fragmenf “butterfly wing”

• Devascularized bone areas under the plate

• Improper drill surfaces

• Holes without screws

Osteitis following centromedullar osteosynthesis

Complex femoral fracture, locked centromedullary osteosynthesis nailing with reaming

a. Devasculraizer internal cortical

b. Bone graft mixed with fracture hematoma

c. Fracture fragments detached from periosteum

d. Medulary canal infection along the nail

• Bridging callus (osteitic) may appear despite infection

Microbiologic and histologic examination

Suture technique in infected wounds

a. Suture points at each 4-6 cm that are securing:

b. Skin

c. Fascia

d. Additional suture points between the deep ones

Reaming medullary canal in chronic infetions

following centromedullar osteosynthesisa. Reaming medullary canal

b. Isolated necrotic areas

c. Sequestration

d. Periosteal and endosteal regeneration

e. Intramedullary fistula abscess

f. Open medullary canal (proximal) or

g. Lateral window

h. Purpose – reamed medullary canal with removal of all necrotic fragments

i. Proximal aspirative drainage

j. Pearls containing cement – gentamycin (local controled-delivery antibioherapy)

Medullary canal reaming

Video V61_7

Infection following subcutaneous wound

a. Peroneal maleolar fracture

b. Plate fixation

c. Result at 1 year postop

d. Day 21: Staphylococcus aureus infection (GA – 18.500, CRP < 5)

e. Debridment and dressing

• Percutaneous catater in the lowest point (irrigation 4-5 times a day by antiseptic)

• Intravenously antibiotic:

• Cephazolin 1 wk

• Cyprofloxacin 4 wk

f. Plate ablation at 6 wk

Progressive favorable evolution

a. Good result at 1 year

Infection following subcutaneous/submuscular plate

a,b. F., 63 yrs, mixed fracture of the external tibial plate

c. Osteosynthesis at the same day

f. Wound cicatrisation impairment and infection by negative coagulase Staphylococcus

g. Reintervention with debridment, irrigation by antiseptic for 2 months

h. Cicatrization after 6 weeks

d,e. Excellent postoperative result at 1 year

Osteoarthritis following plate osteosynthesis

a. F., 83 yrs, distal femoral fracture, osteoporosis

b, c. Fixation by reconstruction metallic plates, one crew slip

d. Day 10:

- pain, GA 11.500, CRP-195

- debridation, articulation closure

- Staphylococcus aureus, Flucoxacillin iv for 3 wk. and Cyprofloxacin 2 mths.

e. Improve clinical status after 10 days of treatment

f. RX result at 2 yrs – arthrosis, flexion/extension deficit

Osteitis following centromedular osteosynthesis (clinical signs at 12 wk postop)

a. Oblique-short tibial fracture

b. Osteosynthesis by dynamic locked plate with reaming

g. Erythema at 9 wk postop.

h. 12 wk: abscess and pain

c. Fracture consolidation

d. Nail ablation, canal reaming, external fixator, antibiogram (S. epidermidis), antibiotherapy (Flucoxacilin i.v. 2 wk. then Clyndamicin orally 4 wk), total weight bearing

e. Fixator removal after 8 wk

f, i. Good postop result at 2 yrs

CHRONIC INFECTIONSCHRONIC INFECTIONSAND INFECTED AND INFECTED

PSEUDATRHROSISPSEUDATRHROSIS

Development of septic pseudarthrosis and its treatment

a,b. Open tibial fracture, plate fixation (internally placed) – intraoperative problems (empty holes)

c. 4 mths postop: infection, plate removal, sequestred tibial fragment, incipient periosteal callus

d. 10 months: complete sequestration of the tibial fragment

e. Debridment, external fixation, cancellous bone graft (secondary procedure)

f. 16 mths: total weight bearing

g. 24 mths: consolidation (discrete varus)

Chronic osteitis classification (Cierny & Mader)

Type I.

Medular osteitis

Type II.

Superficial osteitis in external cortical layer, subcutaneous and skin tissues.

Infection = cortical fragment (S) and granulation tissue

Type III.

Localized osteitis involving the whole bone and adjacent medullary canal (pin or plate infection)

Type IV.

Diffuse osteitis involving the whole bone (pandyaphisitis) leading to extensive devitalization

CT analisys of the fallen bone fragment

Acute infection following closed osteosynthesis, result at 6 years.

Femoral dyaphisis fragment incapsulated in the new formed bone.

Local debridment in an infected pseudarthrosis

After granulation tissue removal:

- Necrotic bone (white) in contrast with healthy bone (red)

Pseudarthrosis covered by granulation tissue stained by methylen-blue

Following debridment of the mortified bone only the healthy bone remains (red)

Debridment of the medullar cavity

(cross section through diaphysis)

Dead bone (not-bleeding - red) is curetted and reamed by a rotative mill.

Infected pseudarthrosis (length preservation)Cortical removalCancellous graftExternal fixation

1. Debrided medial area will be covered by muscle flap or free vascular transfer

2. Cortical removal (from the posterior or lateral peroneal areas or from lateral and dorsal tibial areas)

3. Placement of the cancellous graft

Debridment, cortical removal and cancellous bone graft, compaction

a. Infected pseudarthrosis with fallen fragment (1) and new periosteal bone (2)

b. Debridment, external fixation and 5 mm distraction

c. Cortical removal (leaving the pieces attached to adjacent muscles) and cancellous graft

d. At 6 wks: interlacing between cortical bone and and nude laminas

e. Compression at 12 wks induces graft remodeling and callus formation

Bone segmental transport with a tubular system

a.

• Discrete peroneal shortening

• Infected pseudarthrosis area removal

• Corticotomie proximală

Distraction – 1 mm / day

b.

1. Elongation (4) compensates tibial shortening + removed fragment

Bone segmental transport with a tubular system

– clinical case

a. Infected psudarthrosis at 5 mths following centromedullar osteosynthesis; fallen segment and new periosteal bone formation

b. Tibial resection, peroneal osteotomy and external transport system installation

c. Tibila site consolidation after 9 mths

Peroneal vascular graft in cubital infected pseudarthrosis

Clinical casesClinical cases Emergecy Clinical Hospital Iasi

Clinical casesClinical cases Emergecy Clinical Hospital Iasi

OPEN FRACTURES OF THE DISTAL TIBIAOPEN FRACTURES OF THE DISTAL TIBIA

OPEN FRACTURES OF THE DISTAL TIBIAOPEN FRACTURES OF THE DISTAL TIBIA

SURGICAL DEBRIDMENT – EXTERNAL FIXATIONSURGICAL DEBRIDMENT – EXTERNAL FIXATION

Clinical casesClinical cases Emergecy Clinical Hospital Iasi

LIMB SALVATION vs AMPUTATION

MICROSURGICAL TECHNIQUES

Inflammatory answerResults poor than for immediate amputation

limb salvation opportunities for crushed limbs, partially or total amputated

In politrauma – salvation procedures are generally counterindicated

THE MANGLED EXTREMITY SEVERITY SCORE

OPENED FRACTURE TYPE IIIBOPENED FRACTURE TYPE IIIB

Z.V., M, 26 yrs

Clinical casesClinical cases Emergecy Clinical Hospital Iasi

Clinical casesClinical cases Emergecy Clinical Hospital Iasi

DISTAL TIBIA FRACTURE TYPE B/AODISTAL TIBIA FRACTURE TYPE B/AOOPENED TYPE IIOPENED TYPE II

OSTEO-ARTICULAR INFECIONSOSTEO-ARTICULAR INFECIONS

1.1. FistulaFistulaFallen fragmentFallen fragmentArticular painArticular painKidney amyloidosisKidney amyloidosis

ACUTE OSTEOMYELITISACUTE OSTEOMYELITIS

Metaphyseal circulationMetaphyseal circulation Local abscessLocal abscess

ACUTE OSTEOMYELITISACUTE OSTEOMYELITIS

Abscess migrationAbscess migration::

1.1. Toward articulation Toward articulation2. Subperiost2. Subperiosteealal

ACUTE OSTEOMYELITISACUTE OSTEOMYELITIS

Evolution of the Evolution of the osteomyelitic osteomyelitic sitesite

TOATOASKELETAL BONE LOCALIZATIONSKELETAL BONE LOCALIZATION

Localization Frecventa

Vertebral body 39%

Hip 24%

Knee 18%

Elbow 6.1%

Ankle 4.8%

Wrist 1.8%

Sacroiliac 0.2%

Other articulations 2.7%

TOATOA steps steps

SinovSinovytisytisJJuxtaarticularuxtaarticular bone onset bone onsetTBTB osteoarthritis osteoarthritisFibrous ankylosisFibrous ankylosis

VERTEBRAL TB VERTEBRAL TB (POTT)(POTT)

Most frequent localization Most frequent localization !!

PathologyPathology::

Disc Disc → → adjacent body adjacent body → anterior→ anterior

↓ ↓ fracture on pathological fracture on pathological bonebone

back humpback hump

↓ ↓

medullary dangermedullary danger

VERTEBRAL TB (POTT)(POTT)

CLINIC:CLINIC:OnsetOnset:: General signsGeneral signs

Local: -Local: - functional impairment functional impairment-- rahidianrahidian segment pain segment pain

Rx: - negative 3 Rx: - negative 3 mthsmths - - local osteoporosislocal osteoporosis -- clamped disk clamped diskLab: - Lab: - non-specificnon-specific

StatusStatus: : General signsGeneral signsLocal: -Local: - Angular hump Angular hump / / medianmedian -- Cold abscess Cold abscess -- ParaplegiaParaplegiaRx: - Rx: - SpecificSpecific

RestorationRestoration: : HumpHump Neurological sequelsNeurological sequels

VERTEBRAL TB (POTT)(POTT)

TRTREEATAMENT:ATAMENT:Mainly conservativeMainly conservativeRarely surgcial Rarely surgcial

KNEEKNEE((WHITE TUMORWHITE TUMOR))

IIIIII-rd PLACE-rd PLACECLINICAL PECULIARITIESCLINICAL PECULIARITIES:: OnsetOnset: General: General

SubjectiveSubjective: : PainPainLimpingLimping

Local: HidartLocal: Hidarthhrorosissis AmiotroAmiotrophyphy MMéénardnard AdenopatAdenopathyhy

Rx: Rx: Non specificNon specific

StatusStatus: General: General SubjectiveSubjective: Idem: Idem ObjectiveObjective: : White tumorWhite tumor

Vicious postureVicious posture Cold abscessCold abscess

Rx: Rx: CharacteristicCharacteristic

RestorationRestoration: +/- : +/- SequelsSequels

TOATOA TREATMENT TREATMENT

MEDICALMEDICAL Major medicationMajor medication:: StreptomStreptomyycincinEtambutolEtambutolRifampicinRifampicinIzoniazidIzoniazidee

Accessory medicationAccessory medication:: PASPASEtionamidEtionamideePirazinamidPirazinamidee

ADJUVANTADJUVANT-- Rest Rest-- Climatic cure Climatic cure-- Dietetic cure Dietetic cure

ORTORTHHOPEDICOPEDICImmobilisationImmobilisation

SURGICAL SURGICAL rarrarelyelyBiopsBiopsyyCold abscess drainageCold abscess drainageTOATOA site approach site approachSequelaSequela: Osteotom: Osteotomyy ArtArthhroplastroplastyy ArtArthhroderodesissis

INTRODUCTIONINTRODUCTION

Regarding the increased number of tuberculosis cases reported in Romania in the past 5 years, we have observed the involvement of

the bacillary impregnation in osteoarticular pathology

Bacillar knee osteoarthritis

MATERIAL AND METHODSMATERIAL AND METHODS

female, 73 years, - operated for a femoral neck fracture; - intraoperative - tuberculous trochanteritis - hemiartrhoplasty continued by tuberculostatic treatment

MATERIAL AND METHODSMATERIAL AND METHODS3rd case report3rd case report- fefemale, male, 6868 years, years, - left side coxarthrosis left side coxarthrosis - - operated with an operated with an uncemented total hip prosthesis. uncemented total hip prosthesis. - 7 months from surgery 7 months from surgery - - diagnosed with bacillary diagnosed with bacillary osteoarthritis of the left knee (knee arthrodesis osteoarthritis of the left knee (knee arthrodesis continued by tuberculostatic treatmentcontinued by tuberculostatic treatment))

Diagnosis and evacuatory punctureIntraoperative aspects

DISCUSSIONSDISCUSSIONS3rd case results3rd case results

Femoral bone aspect following resection

Fixation with screws of the bone ends

Final radiological aspect

A tuberculostatic treatment managed for 12 months, led to stabilization and

cure of the bacillary process in all three cases !