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Kesavan Ramanujam

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The Bacteria is nothing, the environment iseverything

-Louis Pasteur

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Chronic Osteomylitis

Cierney Mader Classification

Medullary

Superficial

Localized

Diffuse

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Chronic Osteomylitis

Cierney Mader Classification

Physiological Aspects

1. Host Normal and Healthy

2. Host Immune compromise

Local Factors

Systemic Factors

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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 withOsteomylitis included

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Treatment Principles

Debridement

Soft tissue coverage

Antibiotics

Skeletal sabilisation

Treatment of bone defects

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Orthopaedic infections- Special

Situations

Presence of implanted device

Intra operative seeding

Blood spread

Fretting

Long Op time and high blood loss

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Orthopaedic infections- Special

Situations

GLYCOCALYX

Membrane surrounding the microbes

DILEMMA

To remove or not to remove implants

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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

ratePresence of one organism can lead to

other organisms colonising

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Infected Joint replacements

Prevention better than

cure

1. Laminar Flow

2. Pre op antibiotics

3. Closed body exhaust suits

4. Tissue handling

5. Antibiotic cement

6. Minimise traffic

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Bacterial Biofilm

The glycocalyx

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The culprit bacteria

Staphylococcus aureus

Gram negatives including pseudomona

Anaerobes

Polymicrobes

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Investigations

Radiographs

Aspiration

Bone scans

Intra op frozen sections

Synovial biopsy

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Types of post op infection

Early post op- within 4 weeks

Late chronic infection

Acute haematogenous osteomylitis

Positive intra operative culture

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Treatment

To retain or not

Patient and disease factors

DM, Psoriasis, steroids,

immunocompromised

Virulent bacteris, forming glycoclayx, gram

negative bacteria, poor host bed

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Treatment..

Single stage versus two stage revisions

Gold standard is two stage revisions

Antibiotic duration

Use of antibiotic impregnated cement

Cement spacers

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Salvage methods

Arthrodesis

Resection arthroplasty

Amputation

Prognosis poor

1. Delayed Dx

2. Host poor

3. Poor surgical debridement

4. Virulent organism