• Osteomyelitis- when adequate number of sufficiently virulent organisms are

present and overcome the host defence

• Major source- skin
• Local skeletal role-
– Relatively less number of phagocytes in metaphysis in children-
increased incidence of osteomyelitis in diaphysis
– Pecularity of bone infection:-
• Abcesses are contained in firm structures
• No scope for expansion into bone
• Leads to periosteal elevation- a radiological sign of osteomyelitis
– Bones have poor blood supply-
• less penetration by antibiotics
• Delayed healing
 Patient dependent factors
• Nutritional status
• Can be determined pre-operatively by
– Anthropometric measurements
– S. Proteins+ Leucocyte counts
– Antibody reaction to certain agents
• Nutritional support is recommended for
– Recent weight loss > 10 lb
– S. Albumin levels < 3.5 gm/dL
– Lymphocyte count < 1500/cmm
• Screening formula-
– [(1.2 × serum albumin) + (0.013 × serum transferrin)] − 6.43.
– If value =/< 0 then nutritional supplementation is required
 Patient dependent factors
• Immune status of the patient
• Main defence mechanisms
– Neutrophils-
• against capsulated organisms
• Impaired in- DM, Alcoholics, hematological malignancies
• If neutrophil count<55/cmm
– Staphylococcus aureus, gram-negative bacilli, Aspergillus
organisms, and Candida organisms become a major threat.
– Humoral
• Post spelectomy- more susceptible to encapsulated organisms such as
Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria
organisms
• Complement deficiency- S. aureus and gram-negative bacillus infections
are common
 Patient dependent factors
– CMI
• Corticosteroid therapy, malnutrition, lymphoma, systemic lupus
erythematosus, immunodeficiency in elderly patients
• autoimmune deficiency syndrome
• Predispose to
– Fungal/ Mycobacterial infections
– Herpes
– P. jirovecii
 Surgeon dependant factors
• Skin preparation
– Skin can never be disinfected completely
• Alcohol does not act on sebaceous glands and hair follicles
– Hair removal
• Should be done in OT
• No efficacy if done beforehand in maintaining asepsis
– Hand washing
• Alcohol scrub for 2 mins equally effective as hand washing for 5 mins
• Ideally- 1 min antiseptic wash followed by alcohol based hand rub
– Glove perforation
• Most commonly occur after around 40 mins of operating duration
• Biological indicator gloves
• Double gloving
• Cuffing of gloves to gown
 Surgeon dependant factors
• Operating room environment
– Usual human shedding- 5000-55000 bacteria/min
– Usually gram positive
– Decreased with
• Laminar airflow systems- upto 80% decrease
• Personnel isolator systems- difficult to maintain
• Limiting personnels / Decreasing foot traffic
– Use of UV rooms not recommended due to risk to surgeons
 Prophylactic antibiotic therapy
• Rate of infection depends on number of bacteria present in first 24 hours of
surgery
– First 2 hrs- host mounts immune response- number of pathogens
decrease
– Next 4 hrs- number of pathogens fairly constant
– Next pathogens multiply exponentially
• Golden period-
– First 6 hrs after surgery
• Characteristics of antibotics
– Should be safe
– bactericidal
• Major source of infection is patients skin. Major organisms
– S. aureas/ S. epidermidis
• Evolution of antibiotic resistance esp with S. Epidermidis
– E. coli / Proteus sp.
• 1st gen cephalosporin
• H/O penicillin allergy- Clindamycin
• Should begin immediately before surgery
– 30 mins before incision
– Maximal dose
– If blood loss> 1-1.5 L then repeat 4 hrly
• There is little benefit of continuing antibiotic therapy after 24 hrs post op
• Should not be extended even if drains/catheters in situ
• As per current evidence, 24 hours of antibiotic administration is just as
beneficial as 48 to 72 hours
• Antibiotic irrigation
– Recommended: Neomycin+ Polymixin + Bacitracin
– should be done in open fractures with wound contamination
– Characteristics of antibiotic to be used
• Wide spectrum
• No significant local irritation
• Low systemic absorption / toxicity
• Low allergenicity
• Low potency to induce resistance
• Availability as topical solution
• MRSA
– Approx 57% of Staph aureus
– becoming increasingly prevalent in young, healthy individuals in the community
– Only 3% of patients in ortho infected with Staph aureus
– 57% of infected however have MRSA
– Carriers have higher rates of SSI
– Recommendations for prevention
• Hand hygeine
• Universal decontamination with neomycin before joint or spine surgeries
– Skramm et al concluded that colonies from operating personnel match colonies from
85% cases of SSI with MRSA
– Inv of choice- PCR
– Antibiotics recommended
• For invasive infections- i.v. Vancomycin
• For necrotising fascitis- clindamycin/gentamycin/rifampicin
 Diagnosis
• Clinical features: classical triad
– Pain- most common symptom
– Swelling
– Fever- not consistent
• Lab studies
– ESR
• Non specific
• Normal <48 hrs
• Peaks at 3-5 days
• Returns to normal after 3wks of starting antibiotic therapy
 – CRP
• Increases within 6 hrs of infection
• Peaks at 2 days
• Normalises after 1 week of antibiotic therapy
• Joint aspiration- usually done in septic arthritis
• Other inv
– Gram staining
– ZN staining
• Intra op frozen section
– WBC >10/ HPF: s/o infection
– WBC < 5/ HPF: to r/o infection