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ORTHOPAEDIC

INFECTIONS
Eugene Sherry, MD, MPH, FRACS.
   

  Soft Tissue Infections

Cellulitis - An inflammatory infection of the subcutaneous


tissues, usually due to staph or strep (and Haemophilus in
children). Local erythema, tenderness, and occasionally
lymphangitis/lymphadenopathy make up the clinical picture.
(Fig).Ordinarily, mild cases of cellulitis can be treated with an
Lawn mower injury to arm: oral penicillinase-resistant penicillin or cephalosporin.
prone to cellulitis, gangrene, Patients with high fever, systemic toxicity, poor host
and oseteomyelitis from resistance, or underlying skin diseases should be admitted
implanted debris for IV antibiotic therapy.

Significant Streptococcal Infections - Several serious


diseases are related to specific streptococcal infections.

Erysipelas - Group A strep causes this progressively


enlarging, red, raised, and painful plaque seen preominately
in infants, diabetics, elderly, and patients with predisposing
skin ulcers. Severe toxicity, fever, leukocytosis, and
bacteraemia are common. Treatment with high doses of IV
penicillin is essential for this life-threatening disease.

Necrotising Fasciitis - Aggressive, life-threatening fascial


infection that is often associated with underlying vascular
disease (esp. diabetes).

Meningococcal septicaemia
causing gangrene of four
limbs and necessary
ampuatations

Gas Gangrene - Classically caused by Clostridia species (G+


rod), but also can develop from G - and sometimes G+
Meningococcal septicaemia (strep) infections. Clinical presentation usually includes
causing gangrene of four progressive pain; edema (distant from wound); foul smelling,
limbs and necessary serosanguineous discharge; and feeling of impending doom.
ampuatations May be associated with bowel cancer. Radiographs typically
show widespread gas in tissues. Treatment with high-dose
penicillin (and aminoglycoside and cephalosporin),
hyperbaric oxygen (inhibits toxins), and surgical I&D are
required. See Fig.

Tetanus - Don’t ever forget. Potentially lethal neuroparalytic


disease caused by an exotoxin of Clostridium tetani, a G+
anaerobic rod. Treatment is centred on prophylaxis with
proper wound care and tetanus toxoid administration (and
TIG for patients with severe wounds and without known
previous immunisations). Late management is largely
symptomatic.

Toxic Shock Syndrome - Severe staph infection that usually


develops postoperatively.

Surgical Wound Infection - There has been a recent increase


in the incidence of Staph, epidermidis wound infections.
Staph. aureus is still the most common infection overall, and
in trauma patients. Methicillin-resistant staph species
infections are also increasing.

Puncture Wounds of the Foot - Commonly are infected with


Pseudomonas (from shoewear), and require aggressive
debridement and appropriate antibiotics. Common in
children.

Fungal infections.

Human Immunodeficiency Virus (HIV) Infection - Incidence is


increased in the homosexual population but becoming
increasingly common in heterosexual patients. Additionally,
well over half of the haemophiliacs population is affected. HIV
positivity is not a contraindication to performing required
surgical procedures.

Hepatitis.
Hepatitis A.

Hepatitis B.

Non-A, Non-B Hepatitis.

Hep C.

Bone and Joint Infections

Acute Hematogenous Osteomyelitis - Bone and bone marrow


infection is caused (most commonly) by blood-borne
organisms. Commonly affects children (boys>girls). Staph.
aureus is the most common offender. Anaerobic infections
are also frequently seen, with Peptococcus magnus (G+)
appearing more frequently than Bacteroides (G-). The
infection is most common in the metaphyses or epiphyses of
long bones (lower extremity > upper extremity). Radiographic
changes include soft tissue swelling early, demineralisation
(10 days to 2 weeks), and sequestra (dead bone with
surrounding granulation tissue) and involucrum (periosteal
new bone) later (see POT.....). Pain, loss of function, and
sometimes a soft tissue abscess are present. Elevated WBC
count and ESR and positive blood cultures are usually seen.
Bone scan (delayed up-take in bone) + gallium (in spine
infections) or indium (in extremity infections) scans may be
helpful in equivocal cases. MRI shows changes usually
before plain films (nonspecific low signal intensity in marrow
spaces on both T1 and T2 images). Aspiration is helpful for
antibiotic choice. IV antibiotics followed by a course of oral
antibiotics after the temperature has normalised (total of 6
weeks or until the ESR returns to normal), immobilisation,
and for refractory cases surgical drainage (saving bone from
further destruction) are usually curative. Recurrence is high
for metatarsal lesions (50%), around (25%). Long term
morbidity is >25%.

Subacute Osteomyelitis - Usually discovered radiologically in


a patient with a painful limp and no systemic (and often no
local) signs or symptoms, often from partially treated acute
osteomyelitis, occasionally developing in a fracture
haematoma. Unlike acute osteomyelitis, WBC count and
blood cultures are frequently normal. ESR, bone cultures,
and radiographs are often useful. Most commonly affects the
femur and tibia, and unlike acute osteomyelitis, it can cross
the physis even in older children. Radiographic changes
include Brodie’s abscess, a localised radiolucency usually
seen in the metaphyses of long bones. It is sometimes
difficult to differentiate from Ewing’s sarcoma. When localised
to the epiphysis only, other lesions (such as
chondroblastoma) must be ruled out. Epiphyseal
osteomyelitis is caused exclusively by Staph. aureus.
Treatment of Brodie’s abscess in the metaphysis includes
surgical curettage. Epiphyseal osteomyelitis requires surgical
drainage only if pus is present (48 hours of IV antibiotics
followed by 6 weeks of oral antibiotics is curative otherwise).

Chronic Osteomyelitis - Can follow inappropriately treated


acute osteomyelitis, trauma, or soft tissue spread, especially
in the elderly, immuno-suppressed, diabetics, and IV drug
abusers (Cierney type C host). Staph. aureus, G- rods, and
anaerobes are frequent offending organisms. Often classified
anatomically (Cierney). Skin and soft tissue are often
involved, and fistulous tracts can occasionally develop into
epidermoid carcinoma. Periods of quiescence are often
followed by acute exacerbations. Nuclear medicine studies
are often helpful in determining activity of disease.
Combination IV antibiotics (based on deep cultures), surgical
debridement, bone grafting (open, vascularized, or bypass
[proximal and distal to infected area]), stabilisation (avoid IM
devices following external fixator use with associated pin
tract infections), and soft tissue coverage (flaps) are often
required. Amputations are still often necessary. (See POT).

Chronic Sclerosing Osteomyelitis - An unusual infection that


involves primarily diaphyseal bones of adolescents.

Septic elbow in a child


Chronic Multifocal Osteomyelitis - Caused by an infections
agent appearing in children without systemic symptoms.

Osteomyelitis with Unusual Organisms - Radiographs show


characteristic features in syphilis (T. pallidum; radiolucency in
metaphysis from granulation tissue) and tuberculosis (joint
destruction on both sides of a joint). Histology can also be
helpful (e.g. tuberculosis with granulomas and Langerhan’s
giant cells).

Septic Arthritis - Commonly follows hematogenous spread or


extension of osteomyelitis; can also follow diagnostic or
therapeutic procedures. Bacteria have a special affinity to
exposed collagen matrix. Most cases involve infants (esp.
hip), and children (knee). Fig. Septic elbow young child.
There is pain, swelling, redness and pseudo-paralysis (won’t
move arm). Pus drained. RA (tuberculosis) and drug abuse
(Pseudomonas) can predispose adults. Haemophilus
influenzae is the most common organism in children <5 yo
(Rx chloramphenicol or a third-generation cephalosporin),
staph in children >5 yo (Rx methacillin or oxacillin), and
gonococci in adults (penicillin). Third-generation
cephalosporins (ceftraidime, cefsulodin, and aztreonam) are
now favored over aminoglycosides (with the possible
exception of gentamicin) for the treatment of G- infections.
Surgical drainage (often arthroscopically) or daily aspiration
is the mainstay of treatment. Open drainage is required for
septic hip joints. SI joint sepsis is unusual but is best
diagnosed by physical examination (Flexian Abduction
External Rotation - FABER most specific) and aspiration. A
panus (much like in inflammatory arthritis) can be seen in
tuberculosis infections. Late sequellae of septic arthritis
include soft tissue contractures that can sometimes be
treated with soft tissues procedures such as
quadricepsplasty.

Antibiotics

Antibiotic Delivery

Antibiotic Beads or Spacers.


Osmotic Pump.

Home IV Therapy - useful and cheaper than hospital care.

Other infections

Infected Total Joint Arthroplasty - Perioperative IV antibiotics


are the most effective method of decreasing incidence, but
good operative technique, laminar flow (avoiding obstruction
between the air source and operative wound), and special
space suits also have a role. The ESR is the most sensitive
indicator of infection, but it is nonspecific. Culture of hip
aspirate is very sensitive and specific. C-reactive protein may
be helpful.

Marjolin’s Ulcer - Squamous cell carcinoma that develops in


patients with chronic drainage from sinus tracts. Seen in
untreaded chronic osteomyelitis.

Nutritional Status and Infection - Nutrition is critical in


decreasing the incidence of postoperative infection.
Malnutrition is common after trauma. (See POT).

Postsplenectomy Patients - Need vaccination of


meningococcal and H. influenzae infections.

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