ORTHOPAEDIC INFECTIONS

DARYL M. APLA-ON, MD, FPOA, FPCS

ORTHOPAEDIC INFECTIONS
⚫ Infection of skin and other soft tissue can lead to
infection of bones (osteomyelitis) and joints (septic
arthritis).
⚫ Without prompt treatment, orthopaedic infections
can become chronic. Thus, even a small scratch on the
fingertip has the potential to permanently disable your
hand, or worse.
ORTHOPAEDIC INFECTIONS
⚫ Early diagnosis
⚫ appropriate antibiotic therapy
⚫ surgical intervention when required can cure most
infections and prevent permanent problems.
Soft-Tissue Infections
Common Skin and other soft tissue
⚫ Felon: Infects the pulp of a fingertip
⚫ Paronychia: Appears along the edge of a nail
Impetigo: Appears as a blister in young children or a
yellow crusted ulcer in older people)
⚫ Furuncle: Infects a hair follicle
⚫ Tenosynovitis: Infects the flexor tendons of a finger or
thumb
Paronychia: Appears along the edge of a nail
Furuncle: Infects a hair follicle
Impetigo: Appears as a blister in young children or a yellow crusted ulcer in older people)
Tenosynovitis: Infects the flexor tendons of a
finger or thumb
ORTHOPAEDIC INFECTIONS
Risk Factors
⚫ Having certain chronic diseases puts you at greater risk
for infections.
⚫ Examples include HIV, rheumatoid arthritis, diabetes
mellitus, hemophilia, and sickle cell anemia.
⚫ Direct contact with an infected person or through
indirect contact, as from a contaminated object.
⚫ Infections enter the body through breaks in the skin;
especially puncture wounds and other injuries that are
difficult to clean.
ORTHOPAEDIC INFECTIONS
⚫ Joint infections develop from a previous surgery - hip
or knee replacement device (prosthesis). The knee is
the most commonly infected joint.
Symptoms
⚫ An infection may cause

⚫ redness
⚫ Warmth
⚫ inflammation around the affected area
⚫ The area may be stiff, drain pus, and lose range of
motion

⚫ Infections can give you fever and chills.

Symptoms
⚫ Infants may act irritable
⚫ Lethargic
⚫ Refuse to eat
⚫ Vomit
⚫ Always suspect infection if your child has pain or
swelling in the limbs, spine, or pelvis.
⚫ The child may limp or refuse to walk.
Risk Factors
Infections pose special risks to young children for a number
of reasons:
⚫ Children under the age of 3 are easily infected. Their
immune systems are not fully developed and they tend to
fall down a lot, opening the skin to infection.
⚫ Infections spread quickly through a young child's
circulation system and bone structure.
⚫ Damage to bones and joints caused by infection can harm
a child's growth and lead to severe physical dysfunction.
Infection of child's hip joint is a surgical emergency.
Patient-Dependent Factors
Nutritional Status: Malnutrition
⚫ affects humoral and cell-mediated immunity
⚫ impairs neutrophil chemotaxis
⚫ diminishes bacterial clearance
⚫ depresses neutrophil bactericidal function, the
delivery of inflammatory cells to infectious foci, and
serum complement components
Patient-Dependent Factors
⚫ Nutritional Status
(1) anthropometric measurements (height, weight,
triceps skin fold thickness, and arm muscle
circumference),
(2) measurement of serum proteins or cell types
(lymphocytes)
(3) antibody reaction to certain antigens in skin testing.
Patient-Dependent Factors
Immunological Status
⚫ The body's main defense mechanisms are:
(1) neutrophil response
(2) humoral immunity
(3) cell-mediated immunity
(4) reticuloendothelial cells
Patient-Dependent Factors
⚫ Deficiencies in the immune system may be acquired or may
result from congenital abnormalities.
⚫ Immunocompromised hosts are not susceptible to all
opportunistic pathogens.
⚫ The susceptibility to a microorganism depends on the specific
defect in immunity.
⚫ Abnormal neutrophils or humoral and cell-mediated
immunities
⚫ encapsulated bacteria in infants and elderly patients
⚫ Pseudomonas infections in heroin addicts
⚫ Salmonella and Pneumococcus infections in patients with sickle
cell anemia.
Patient-Dependent Factors
Surgeon-Dependent
⚫ Skin Preparation
Factors
Surgeon-Dependent Factors
Operating Room Environment
⚫ Airborne bacteria are another source of wound
contamination in the operating room.
⚫ These bacteria usually are gram positive and originate
almost exclusively from humans in the operating room
⚫ 5,000 to 55,000 particles are shed per minute by each
individual in the operating room.
Surgeon-Dependent Factors
⚫ Conventional operating room air may contain 10 to 15
bacteria per cubic foot and 250,000 particles per cubic
foot.
⚫ Use of laminr flow system

⚫ Laminar flow is air moving at the same speed and in the

same direction, with no or minimal cross-over of air
streams (or “lamina”).
⚫ By contrast, turbulent flow creates swirls and eddies that
deposit particles on surfaces randomly and unpredictably.
Prophylactic Antibiotic Therapy
⚫ “Golden period” – 6-8 hours post injury
⚫ safe, bactericidal, and effective against the most
common organisms causing infections in orthopaedic
surgery
⚫ Staphylococcus aureus
DIAGNOSIS
⚫ The diagnosis of infection may be obvious or obscure.
⚫ Signs and symptoms vary with the rate and extent of bone and joint
involvement.
⚫ Characteristic features of fever, chills, nausea, vomiting, malaise,
erythema, swelling, and tenderness may or may not be present.
⚫ The classic triad is fever, swelling, and tenderness (pain).
⚫ Pain probably is the most common symptom.
⚫ Fever is not always a consistent finding.
⚫ Infection also may be as indolent as a progressive backache or a
decrease in or loss of function of an extremity.
⚫ No single test is able to serve as a definitive indicator of the
presence of musculoskeletal infection.
Laboratory Studies
⚫ CBC
⚫ ESR – sensitive but not specific
⚫ CRP – response to treatment
Imaging Studies
⚫ Patients suspected of musculoskeletal infection
should have plain radiographs of the area in question.

⚫ CT is useful in detecting bone abnormalities such as

sequestra.

⚫ Ultrasonography helps to establish if a joint effusion is

present and to localize needle aspiration to diagnose
septic arthritis.
Imaging Studies
⚫ A three-phase bone scan accurately detects osteomyelitis
in nonviolated bone.
⚫ If hardware is in place or if there has been previous
trauma to the bone or a Charcot joint for instance is
present, a three-phase bone scan is only useful as a
screening test.
⚫ A white blood cell–labeled bone scan helps with detection
of complicated osteomyelitis, and combining this with a
colloid scan maximizes accuracy.
⚫ Useful in total joint infections and diabetic feet but less so
in neuropathic joints
Imaging Studies
⚫ MRI shows surrounding tissue and is excellent in
detecting osteomyelitis. Adding gallium improves
detection of spinal osteomyelitis.
⚫ FDG-PET also is helpful in the diagnosis of spinal
infection and chronic osteomyelitis but is not readily
available in all health care institutions.
Culture Studies
⚫ An actual bacteriological diagnosis that would allow
development of a treatment plan including correct
antibiotic selection.
Osteomyelitis
Classification criteria
Duration
⚫ acute
⚫ Subacute
⚫ chronic
The mechanism of infection
⚫ Exogenous - caused by open
⚫ fractures, surgery (iatrogenic), or contiguous spread
from infected local tissue
⚫ Hematogenous - results from bacteremia

Based on the host response to the disease.

⚫ Pyogenic
⚫ nonpyogenic
ACUTE HEMATOGENOUS
OSTEOMYELITIS

⚫ most common type of bone infection and usually is

seen in children
⚫ Decreased incidence due to increasing higher standard
of living and improved hygiene
⚫ More in males
⚫ infection generally involves the metaphyses of rapidly
growing long bones.
Pathophysiology
SUBACUTE HEMATOGENOUS
OSTEOMYELITIS

⚫ more insidious onset

⚫ lacks the severity of symptoms
⚫ relatively common
⚫ occur in over a third of patients with primary bone
infections.
SUBACUTE HEMATOGENOUS
OSTEOMYELITIS
⚫ Indolent course
⚫ diagnosis typically is delayed for more than 2 weeks.
⚫ Systemic signs and symptoms are minimal.
⚫ Temperature is only mildly elevated if at all.
⚫ Mild-to-moderate pain is one of the only
⚫ consistent signs suggesting the diagnosis.
⚫ Normal WBC count
⚫ ESR is elevated in 50% of patients
⚫ blood cultures usually are negative.
⚫ Even with an adequate bone aspirate or biopsy specimen, a pathogen
is identified only 60% of the time.
⚫ Plain radiographs and bone scans generally are positive
SUBACUTE HEMATOGENOUS
OSTEOMYELITIS
The indolent course of subacute osteomyelitis is thought to be
the result of:
⚫ increased host resistance,
⚫ decreased bacterial virulence
⚫ administration of antibiotics before the onset of symptoms.

⚫ allow the inflammation to persist in bone without producing

significant signs or symptoms.

⚫ correct diagnosis largely depends on clinical suspicion and

radiographic findings.
BRODIE ABSCESS
⚫ localized form of subacute osteomyelitis
⚫ occurs most often in the long bones of the lower
extremities of young adults.
⚫ Presenting complaint - Intermittent pain of long
duration with local tenderness over the affected area.
BRODIE ABSCESS
⚫ lytic lesion with a rim of
sclerotic bone
⚫ can be easily mistaken
for a variety of
neoplasms.
CHRONIC OSTEOMYELITIS
⚫ difficult to eradicate completely.
⚫ Systemic symptoms may subside, but one or more foci in the bone may
contain purulent material, infected granulation tissue, or a
sequestrum.
⚫ Intermittent acute exacerbations may occur for years and often
respond to rest and antibiotics.
⚫ The hallmark of chronic osteomyelitis is infected dead bone within a
compromised soft tissue envelope.
⚫ secondary infections are common
⚫ sinus track cultures usually do not correlate with cultures obtained at
bone biopsy
⚫ Multiple organisms may grow from cultures taken from sinus tracks
and from open biopsy specimens of surrounding soft tissue and bone
Classification
Diagnosis
⚫ The “gold standard” is to obtain a biopsy specimen for
histological and microbiological evaluation of the
infected bone.
⚫ CT provides excellent definition of cortical bone and a
fair evaluation of the surrounding soft tissues and is
especially useful in identifying sequestra.
⚫ MRI is more useful for soft tissue evaluation &
provides a fairly accurate determination of the extent
of the pathological insult by showing the margins of
bone and soft tissue edema
Treatment
⚫ Debridement, Currettage and Sequestrectomy
Treatment
Antibiotic treatment (6 weeks)
Thank you for listening.