Lecture 2 Bone Infections

OSTEOARTICULAR INFECTIONS

ACUTE INFECTIONS

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

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 osteosynthesis a. 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

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)

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Intravenously antibiotic: •

Cephazolin 1 wk

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Cyprofloxacin 4 wk

a. 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 INFECTIONS AND INFECTED PSEUDATRHROSIS

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

Pseudarthrosis covered by granulation tissue stained by methylen-blue

After granulation tissue removal: - Necrotic bone (white) in contrast with healthy bone (red)

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 removal Cancellous graft External 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

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Infected pseudarthrosis area removal

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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 cases

Emergecy Clinical Hospital Iasi

Clinical cases

Emergecy Clinical Hospital Iasi

OPEN FRACTURES OF THE DISTAL TIBIA

OPEN FRACTURES OF THE DISTAL TIBIA

SURGICAL DEBRIDMENT – EXTERNAL FIXATION

Clinical cases

Emergecy Clinical Hospital Iasi

LIMB SALVATION vs AMPUTATION MICROSURGICAL TECHNIQUES  limb salvation opportunities for crushed limbs, partially or total amputated In politrauma – salvation procedures are generally counterindicated  Inflammatory answer Results poor than for immediate amputation

THE MANGLED EXTREMITY SEVERITY SCORE

OPENED FRACTURE TYPE IIIB

Z.V., M, 26 yrs

Clinical cases

Emergecy Clinical Hospital Iasi

Clinical cases

Emergecy Clinical Hospital Iasi

DISTAL TIBIA FRACTURE TYPE B/AO OPENED TYPE II

OSTEO-ARTICULAR INFECIONS

1.

Fistula Fallen fragment Articular pain Kidney amyloidosis

ACUTE OSTEOMYELITIS

Metaphyseal circulation

Local abscess

ACUTE OSTEOMYELITIS

Abscess migration: 1. Toward articulation 2. Subperiosteal

ACUTE OSTEOMYELITIS

Evolution of the osteomyelitic site

TOA SKELETAL 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%

TOA steps

Sinovytis Juxtaarticular bone onset TB osteoarthritis Fibrous ankylosis

VERTEBRAL TB (POTT) Most frequent localization !

Pathology: Disc → adjacent body → anterior ↓ fracture on pathological bone back hump ↓ medullary danger

VERTEBRAL TB (POTT)

VERTEBRAL TB (POTT) CLINIC: Onset: General signs Local: - functional impairment - rahidian segment pain Rx: - negative 3 mths - local osteoporosis - clamped disk Lab: - non-specific Status: General signs Local: - Angular hump / median - Cold abscess - Paraplegia Rx: - Specific Restoration: Hump Neurological sequels

TREATAMENT: Mainly conservative Rarely surgcial

KNEE (WHITE TUMOR) III-rd PLACE CLINICAL PECULIARITIES: Onset: General Subjective: Pain Limping Local: Hidarthrosis Amiotrophy Ménard Adenopathy Rx: Non specific Status: General Subjective: Idem Objective: White tumor Vicious posture Cold abscess Rx: Characteristic Restoration: +/- Sequels

TOA TREATMENT MEDICAL

Major medication: Streptomycin Etambutol Rifampicin Izoniazide Accessory medication: PAS Etionamide Pirazinamide

ADJUVANT - Rest - Climatic cure - Dietetic cure ORTHOPEDIC Immobilisation SURGICAL rarely Biopsy Cold abscess drainage TOA site approach Sequela: Osteotomy Arthroplasty Arthrodesis

INTRODUCTION

Bacillar knee osteoarthritis

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

MATERIAL AND METHODS

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

MATERIAL AND METHODS 3rd case report - female, 68 years, - left side coxarthrosis - operated with an uncemented total hip prosthesis. - 7 months from surgery - diagnosed with bacillary osteoarthritis of the left knee (knee arthrodesis continued by tuberculostatic treatment)

Diagnosis and evacuatory puncture

Intraoperative aspects

3rd case results

DISCUSSIONS

Femoral bone aspect following resection

Fixation with screws of the bone ends

A tuberculostatic treatment managed for 12 months, led to stabilization and cure of the bacillary process in all three cases ! Final radiological aspect