bone infection
TRANSCRIPT
Posttrauma*candpostsurgicalboneinfec*on
ByAhmedHashimAli4thyearICMSortho
Contents
• Infectedfractures:– Openfractures.– Post-Opera*veInfec*oninClosedFracturesTreatedwithInternalFixa*on
• Prosthe*cJointInfec*on(PJI).
Infectedfracture
• Openfractures– Gus*loandAndersonin1976.*– Gus*loModifica*onin1984.**
*Gus*loRB,AndersonJT.Preven*onofinfec*oninthetreatmentofonethousandandtwenty-fiveopenfracturesoflongbones:retrospec*veandprospec-*veanalyses.JBoneJointSurgAm.1976;58(4):453–8.**Gus*loRB,MendozaRM,WilliamsDN.ProblemsinthemanagementoftypeIII(severe)openfrac-tures:anewclassifica*onoftypeIIIopenfractures.JTrauma.1984;24(8):742–6.
• Gus*lotypeIandII,isalowenergyfractures.• typeIIIA:aconsiderabledegreeofso^-*ssuedamage.
• typeIIIB:localorafree*ssuetransfer.• typeIIIC:vascularsurgeryismandatoryforsalvageoftheextremity.
Openfracturesandrateofinfec*on
• lessthan5%infec*onintypeIandII• lessthan10%infec*onintypeIIIA• 30–50%infec*onintypeIIIBandIIIC
BowenTR,WidmaierJC.Hostclassifica*onpredictsinfec*ona^eropenfractures.ClinOrthopRelatRes.2005;433:205–11.
Controversies
• objec*onstotheGus*loclassifica*on
BrumbackRJ,JonesAL.Interobserveragreementintheclassifica*onofopenfracturesofthe*bia.JBoneJointSurgAm.1994;76(8):1162–6.TemplemanDC,GulliB,TsukayamaDT,Gus*loRB.Updateonthemanagementofopenfracturesofthe*bialsha^.ClinOrthopRelatRes.1998;350:18–25.
Otherfactorsinfluencingtherateofinfec*on
• TheTimeFactor• TheLoca*onoftheFracture• TheHost
TheTimeFactor
• Debridementassoonaspossible*• Tissuecoverageassoonaspossible.• IIIB1• IIIB2• infec*onandnon-unionratesofmorethan50%**.
*CrowleyDJ,KanakarisNK,GiannoudisPV.Debridementandwoundclosureofopenfractures:theimpactofthe*mefactoroninfec*onrates.Injury.2007;38(8):879–89.**ChoudryU,MoranS,KaracorZ.So^-*ssuecover-ageandoutcomeofGus*logradeIIIBmidsha^*biafractures:a15-yearexperience.PlastReconstrSurg.2008;122(2):479–85.**GopalS,MajumderS,BatchelorAGB,KnightSL,DeBoerP,SmithRM.Fixandflap:theradicalorthopaedicandplas*ctreatmentofsevereopenfracturesofthe*bia.JBoneJointSurgBr.2000;82(7):959–66.
TheLoca*onoftheFracture
• openfracturesofthedistalone-thirdofthe*biahaveahigherrateofinfec*oncompared
*BowenTR,WidmaierJC.Hostclassifica*onpredictsinfec*ona^eropenfractures.ClinOrthopRelatRes.2005;433:205–11.*PatzakisMJ,WilkinsJ.Factorsinfluencinginfec*onrateinopenfracturewound.ClinOrthopRelatRes.1989;243:36–40.
TheHost
• Waldvogelclassifica*on1970• Cierny-Maderclassifica*on
TreatmentofOpenFractures
1. Immediatedebridementandirriga*on,includingrepeateddebridementandirriga*onoftypeIIIfracturesat24–48hintervals
2. An*bio*ctherapy3. Securefracturestability4. Woundcoverage,eitherbydelayedprimary
closureorbylocalorfreeflaps5. Earlycancellousbonegra^ing6. Makeanearlydecisiononamputa*on.
Post-Opera*veInfec*oninClosedFracturesTreatedwithInternal
Fixa*on• Theaim:
– avoidachronicinfec*on.– avoidinfectedpseudarthrosis.
• Earlyandlate.– 4weeks.
• Within4weeks:– radicalso^-*ssuedebridement,harves*ngof*ssuebiopsiesforcultureandwoundclosure.
– Stable??.• A^er4weeks:– Theimplantshouldberemoved.– Extfixa*on.– staph.*
• alargedeadspacethatneedstobemanagedeffec*velytopreventrecurrenceofinfec*on.
• Themanagementofthedeadspaceinthisselngincludes– closedirriga*onsystems,– localso^*ssueflaps,– vascularizedfreeflaps,– avarietyofmethodsforlocalan*bio*cdelivery
Prosthe*cJointInfec*ons
• Aprosthe*cjointinfec*on(PJI)isanyinfec*onduetobacteriaorfungiinatotalorhemi-arthroplasty.
• Classifica*on:– StageIinfec*on(acuteinfec*on)– StageII(delayedinfec*on)– StageIIIpresentsasahaematogenous
*CoventryMB.Treatmentofinfec*onsoccurringintotalhipsurgery.OrthopClinNorthAm.1975;10(4):991–1003.*FitzgeraldRH,NolanDR,IlstrupDM,VanScoyRE,WashingtonJA,CoventryMB.Deepwoundsepsisfollowingtotalhiparthroplasty.JBoneJointSurgAm.1977;59:847–55.
• acutePJIbecomeschronica^erfewweeks– StageIPJI:Anacutepost-opera*veinfec*onthatoccurs<4weeksa^erimplanta*on.
– StageIIPJI:Achronicinfec*onthatoccurs>4weeksa^erimplanta*on.
– StageIIIPJI:Ahaematogenousinfec*on.
Diagnosis:
Clinical
Image
Management:
• Thedifferentop*onsfortreatmentofaPJIis:– so^*ssuedebridement,– one-stageortwo-stageprosthe*crevision,– permanentresec*onarthroplasty(Girdlestone)orarthrodesis,
– an*microbialsuppressiontherapy,– amputa*on.
Takehomemessage
• Treatearly.• Don’tfixsuspiciousbone.• Earlylooseningmeansinfec*on.
Goodluck