ORTHOPAEDIC INFECTION

Aries Budianto

The most challenging and serious complication Delay in diagnosis Difficulty in prompt bacterial identification Emergence of resistant bacteria Prevention

Common access
Hematogenous seeding Contigous spreading

Bacteria
Destroyed by the host Live in symbiosis Flourish and cause host sepsis

Acute infections after osteosynthesis are generally exogenous Contamination occurs from :

trauma (open fracture) during osteosynthesis after osteosynthesis

Hematogenous infection after ORIF is very rare

Perioperative prophylaxis
Standard practice in surgery using implant Aseptic surgery Avoidance of risk factors Antibiotic prophylaxis

Risk factors for surgical site infection

High age Comorbidity Drug Preoperative hospitalization Remote infection Nasal carriage of S. aureus

Procedure-related
Early preoperative hair removal Shaving vs hair clipping Lengthy surgical procedure Traumatic or unfamiliar surgical technique Prolonged drainage Emergency procedure

Microbiology of bone deviceassociated infection

Coagulase-negative staphylococci

S. aureus

Gram negative bacilli Streptococci Anaerobes Enterococci Other

Correct timing of prophylaxis

Inhibitory antimicrobial tissue level must be achieved at the time of incision and during the whole procedure 60 minutes before incision 10 minutes before the torniquet is inflated

Early first manifestation

Disturbance of wound healing Wound edge necrosis Wound hematoma

Clinical and laboratory findings

Redness, pain, fever Lab. Leukocyte count, CRP

Chronic infection

The goals in the treatment of chronic osteomyelitis

to eradicate the infection maintain optimum physiologic function for the affected area

The consequences of this infection range from the minor nuisance of a draining tract, to a pathologic fracture at the infected site, to the possible malignant transformation to squamous cell carcinoma in a draining tract.

The chronicity of osteomyelitis is multifactorial

The relative avascular and ischemic nature of the infected region and sequestrum produces an area of lowered oxygen tension as well as an area that antibiotics cannot penetrate

The lowered oxygen tension effectively reduces the bacteriocidal activities of polymorpholeukocytes and also favors the conversion of a previously aerobic infection to one that is anaerobic

The consequence of the ischemia within the sequestrum and surrounding infected areas is a lowering of the antibiotic levels in these sites This may lead to ineffective antibiotic concentrations at the site of infection despite serum levels indicating therapeutic concentrations. The increased frequency of antibiotic usage as well as the wider variety of antibiotics has resulted in the emergence of resistant organisms, often to multiple antibiotics

chronic osteomyelitis tends to be polymicrobial both in terms of aerobic and anaerobic microorganisms An open wound or sinus tract is always a potential source of superinfection In instances where proper antibiotic therapy was started to treat the organisms initially recovered from the infected site, there is the potential for successive infections with more virulent, more resistant, or opportunistic organisms

antibiotics alone are ineffective surgery has been primarily directed at removing all infected material including surrounding scar tissue in order to restore adequate blood flow to the area

Devitalized fragments become sequestra

Diagnosis
Chronic drainage Pain Erythema Edema

Lab
ESR CRP Lekocyte Bacteriological analysis

Treatment
Eradication of the infection Creation of viable and stable soft tissue environment Reconstruction, alignment, and stabilization