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 fragments)
d. Preceding perforaion, correct pin
placement
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
i. Proximal aspirative drainage
j. Pearls containing cement – gentamycin
(local controled-delivery antibioherapy)
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)
• Intravenously
antibiotic:
• Cephazolin 1 wk
• Cyprofloxacin 4 wk
f. 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.
 Cortical removal
Infected pseudarthrosis (length preservation) 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
• Infected pseudarthrosis area removal
• 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 TREATAMENT:
Rx: - negative 3 mths Mainly conservative
- local osteoporosis Rarely surgcial
- clamped disk
Lab: - non-specific

Status: General signs

Local: - Angular hump / median
- Cold abscess
- Paraplegia
Rx: - Specific

Restoration: Hump
Neurological sequels
 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)

Intraoperative aspects
Diagnosis and evacuatory puncture
 DISCUSSIONS
3rd case results

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