INFECTIONS IN

ORTHOPAEDIC
Aditya Priherdadi

introduction
Microbial pathogenesis remains
one of the greatest public health
issues.
Focus on bone infection
Consist of :

modes of transmission and pathogen

virulance
host response, diagnosis, and treatment
special infections pertinent to health
care workers

terminology
Osteomyelitis

Based on
route of
entry

Haematogenous
osteomyelitis
Nonhaematogenous
osteomyelitis

Based on
duration

Acute osteomyelitis
Chronic Osteomyelitis

interplay between host and

pathogen
Environment
-traumatic
injury
-foreign body

Host
-skin
-mucous
-host
anatomy

Pathogen
bacteria

haematogenous
osteomyelitis

Infection enters into the

bloodstream at a distant site
and seed the bone

Commonly in children and

joint arthroplasty

Pathogen varies according

to :
age
immune status
circumstances of the infection

direct transmission
Bacteria

enter the host bone from

adjacent tissue
The infected bone associated with
ischaemic ulcer
Polymicrobial osteomyelitis is seen when
osteomyelitis adjacent to colonized ulcer
necrotic tissue and foreign bodies
Necrotic bone and foreign bodies provide
surfaces that facilitate bacterial
attachment.

Bacterial attachment species produce a

biofilm protective shield protective
properties from strong bonds difficulty in
eradicating bacteria from bone

post traumatic
osteomyelitis
Common cause is trauma
Unusual complication of close
fracture, but in open fracture can
exceed 40%
Exposure of bone does not
necessarily result in osteomyelitis
Certain environment exposure
associated with high risk for
specific infection

post traumatic
osteomyelitis
most instance caused by hospitalacquired pathogens
Environmental exposure misleading
deep culture
once inside host pathogenic bacteria
express unique set of virulance genes
and protein infection
target of receptor : collagen, laminin,
bone sialoglycoprotein, and fibronectin
Mutant strains of bacteria serve as
vaccines

virulence factors and host injury

bacteria biofilm impair
antibody adhesion excessive
release of cytokines injured host
tissue, provide area of refuge of
pathogen

Pathogen

toxins injury to the host

degrade host tissue disrupt
host cells

Bacteria

the host response to osteomyelitis

Innate Immune Response

Infection acute inflammatory reaction

tissue injury bacteria trigger activation

Local
vasodilatation
Tissue edema
Migration of PMNs
Injured tissue released cytokines (Il-1, Il-6,
TNF) chemotactic & activators of PMNs
and macrophage free oxygen radicals

adaptive immune response

involve 2 mechanisms :
1. Cellullar respons, cytotoxic or CD8 + T
lymphocytes
2. Humoral repons, B lymphocytes
produce antibodies against the bacteria
. Reach peak effectiveness in 2 weeks
. Once bacteia are cleared, the antigenic
challege diminished, memory T and B
lymphocytes persist

Cierny-Mader
classification

clinical characteristics and diagnosis

of osteomyelitis
Bone infection
pain
swelling
sinus tract drainage
Infarction of marrow
fat, haemopoetic cells,
ischemic necrosis of
bone devascularized
fragment (sequestra)
encases in new bone
( involucrum)

Bacterial products osteolysis by

inducing proinflammatory factors
(PGE2, TNF-, IL- 1 and IL-6)
Evaluation patients with clinical
signs, but proper diagnosis requires
fluid and tissue culture (CBC with
differential, ESR, CRP)
radiographic signs occurs at least 2
weeks bone scan

Phase of bone scan :

first phase : flow
phase
second phase : blood
pool phase,
third phase , bone
image after 3 hours
after injection
fourth phase : after
4 hours

Another test :
gallium citrate (Ga 67)
white blood scan
CT
MRI

treatment
Consist of acquisition of deep and
blood cultures and surgical
debridement of infected and necrotic
tissue
Antibiotics rarely > 4 weeks, except
in patients with diabetic, metabolic or
immune compromise antibiotics
administration for 4-6 weeks
clinical finding, ESR and CRP

Chronic infection with extensive

devitalized tissue soft tissue
debridement and reconstruction
fascilitate bone healing

Bone defect filled with allogenic or

autogenic bone graft, initially dead
space filled with antibiotics infused
polymehylmethacrylate beads

infections and total joint

arthroplasty
incidense < 1% for primary surgery
and 2% for revision surgery
Similar to osteomyelitis, septic
arthritis
Laboratory studies : ESR, CRP,
complete blood count with differential
+ aspiration of joint fluid and
surgically obtained tissue sample
gram stained, culture, number of
PMN white blood cells per HPF

The most powerful technique in

diagnosis is PCR
Radiographic test :

plain radiographic
MRI
indium (In) 111
technetium (Tc) 99m methylene

diphosponate

Treatment same basic principles

for treatment for osteomyelitis
Debridement treatment involve a
two-stage exchage or three-stage
program

prophylactic antibiotic treatment of

patient with total joint arthroplasties

Despite complications such as

infection and aseptic loosening, all
patients undergoing total joint
arthroplasty procedures should
receive antibiotic prophylaxis
reduce the risk of infection from 28%
to zero

antibiotic and drug resistance

Developed based on ability to inhibit
the growth or kill bacteria
In general divide into five
categories ;

1.
2.
3.
4.
5.

inhibition of cell wall synthesis

alteration of cell membrane permeability
inhibition of bacterial metabolism
inhibition of protein synthesis
Interference with nuclei acid synthesis

Bacteria may also express

phenotypic resistance to
antibiotics high failure rate of
short courses therapy.
Bacteria have derived three
basic mechanisms to counter the
effectiveness of an antibiotic :

1.
2.
3.

avoidence
decreased susceptibility
inactivation

S aureus mutans the most

troubling to the orthopaedic surgeon
The bacteria resistance pursue
the highest degree in antibiotic use
and the search for novel antibiotic
drugs
Drug treatment cant replace the
surgical care of patients with
orthopaedic infection

tuberculosis
Caused by M. Tuberculosa, but can
also caused by M. Africanum & M.
Bovis
Decolorization using Ziehl-Neelsen
carbofuhsinvstaining methods.
Transmission, spread from lung to
lung in microscopic aerosol, produced
from cough, sneezing, or even face to
face conversation

Prophylaxis
vaccination with
attenuated M
bovis
Diagnosis :

skin test for

tuberculosis
clinical & symptoms
cultures
radiographs

Most tuberculosis infections occur in

the lung extrapulmonary
Most common area is thoracic spine
Treatment : surgical prevent spinal
deformity, paraplegia, drain abscess
from major joint
If infection destroyed major joint
arthrodesis or arthroplasty

viral disease

Most serious viral infection : HIV,

HBV, HCV

Present danger that extend beyond

the primary infecton, post operative
complication and transmission to
health care providers

viral transmission in the

surgical setting

Type exposure :
percutaneous injury
mucocutaneous exposure
skin

Risk of percutaneous injury in orthopaedic

procedures increase with : length of

procedure, amount of blood lost, presence of
sharp objects

summary
Musculoskeletal infection to be among the
most difficult condition to treat in orthopaedic
surgery
The age and health of individual plays role in
treatment
Antibiotic resistance become more prevalent
hamper management
TB, viral hepatitis, and HIV importance to
health care workers
Advances management with understanding
the molecular mechanism , pathology, and the
tools used to treat

thank you