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Kesavan Ramanujam
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The Bacteria is nothing, the environment iseverything
-Louis Pasteur
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Chronic Osteomylitis
Cierney Mader Classification
Medullary
Superficial
Localized
Diffuse
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Chronic Osteomylitis
Cierney Mader Classification
Physiological Aspects
1. Host Normal and Healthy
2. Host Immune compromise
Local Factors
Systemic Factors
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Cierney Mader
Classification Medullary- Haematogenous Osteomylitis
Superficial- Ulcer with Exposed Bone
Localised- Cortex with Medullary
involvement
Diffuse- Cortical with Extension into
medullary canal. Infected non-unions
and Total joint infections withOsteomylitis included
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Treatment Principles
Debridement
Soft tissue coverage
Antibiotics
Skeletal sabilisation
Treatment of bone defects
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Orthopaedic infections- Special
Situations
Presence of implanted device
Intra operative seeding
Blood spread
Fretting
Long Op time and high blood loss
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Orthopaedic infections- Special
Situations
GLYCOCALYX
Membrane surrounding the microbes
DILEMMA
To remove or not to remove implants
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Case scenarios
Infected non union difficult to treat
Infection rate high in inadequately fixed
fractures
Poor fixation worse than no metal
Rigid fixation can further reduce infection
ratePresence of one organism can lead to
other organisms colonising
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Infected Joint replacements
Prevention better than
cure
1. Laminar Flow
2. Pre op antibiotics
3. Closed body exhaust suits
4. Tissue handling
5. Antibiotic cement
6. Minimise traffic
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Bacterial Biofilm
The glycocalyx
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The culprit bacteria
Staphylococcus aureus
Gram negatives including pseudomona
Anaerobes
Polymicrobes
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Investigations
Radiographs
Aspiration
Bone scans
Intra op frozen sections
Synovial biopsy
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Types of post op infection
Early post op- within 4 weeks
Late chronic infection
Acute haematogenous osteomylitis
Positive intra operative culture
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Treatment
To retain or not
Patient and disease factors
DM, Psoriasis, steroids,
immunocompromised
Virulent bacteris, forming glycoclayx, gram
negative bacteria, poor host bed
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Treatment..
Single stage versus two stage revisions
Gold standard is two stage revisions
Antibiotic duration
Use of antibiotic impregnated cement
Cement spacers
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Salvage methods
Arthrodesis
Resection arthroplasty
Amputation
Prognosis poor
1. Delayed Dx
2. Host poor
3. Poor surgical debridement
4. Virulent organism
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