This document discusses post-traumatic and post-surgical bone infections. It covers infected fractures including open fractures classified using the Gustilo system, as well as post-operative infections in closed fractures treated with internal fixation. It also discusses prosthetic joint infections, how they are classified, diagnosed, and treated through options like debridement, revision surgery, or amputation. Throughout, it emphasizes the importance of early treatment and debridement to prevent infection.

1. Post trauma*c and post surgical
bone infec*on
By
Ahmed Hashim Ali
4th year ICMS ortho

4. Contents
• Infected fractures:
– Open fractures.
– Post-Opera*ve Infec*on in Closed Fractures
Treated with Internal Fixa*on
• Prosthe*c Joint Infec*on (PJI).

5. Infected fracture
• Open fractures
– Gus*lo and Anderson in 1976.*
– Gus*lo Modifica*on in 1984.**
* Gus*lo RB, Anderson JT. Preven*on of infec*on in the treatment of one thousand and twenty-five open fractures of long bones: retrospec*ve and prospec- *ve analyses. J Bone Joint Surg Am. 1976; 58(4):453–8.
** Gus*lo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open frac- tures: a new classifica*on of type III open fractures. J Trauma. 1984;24(8):742–6.

6. • Gus*lo type I and II, is a low energy fractures.
• type IIIA: a considerable degree of so^-*ssue
damage.
• type IIIB: local or a free *ssue transfer.
• type IIIC: vascular surgery is mandatory for
salvage of the extremity.

7. Open fractures and rate of infec*on
• less than 5 % infec*on in type I and II
• less than 10 % infec*on in type IIIA
• 30–50 % infec*on in type IIIB and IIIC
Bowen TR, Widmaier JC. Host classifica*on predicts infec*on a^er open fractures. Clin Orthop Relat Res. 2005;433:205–11.

8. Controversies
• objec*ons to the Gus*lo classifica*on
Brumback RJ, Jones AL. Interobserver agreement in the classifica*on of open fractures of the *bia. J Bone Joint Surg Am.
1994;76(8):1162–6.
Templeman DC, Gulli B, Tsukayama DT, Gus*lo RB. Update on the management of open fractures of the *bial sha^. Clin Orthop
Relat Res. 1998; 350:18–25.

10. Other factors influencing the rate of
infec*on
• The Time Factor
• The Loca*on of the Fracture
• The Host

11. The Time Factor
• Debridement as soon as possible *
• Tissue coverage as soon as possible.
• IIIB1
• IIIB2
• infec*on and non-union rates of more than 50
% **.
* Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: the impact of the *me factor on infec*on
rates. Injury. 2007;38(8):879–89.
** Choudry U, Moran S, Karacor Z. So^-*ssue cover- age and outcome of Gus*lo grade IIIB midsha^ *bia fractures: a 15-year experience.
Plast Reconstr Surg. 2008;122(2):479–85.
** Gopal S, Majumder S, Batchelor AGB, Knight SL, De Boer P, Smith RM. Fix and flap: the radical orthopaedic and plas*c treatment of severe
open fractures of the *bia. J Bone Joint Surg Br. 2000;82(7):959–66.

12. The Loca*on of the Fracture
• open fractures of the distal one-third of the
*bia have a higher rate of infec*on compared
* Bowen TR, Widmaier JC. Host classifica*on predicts infec*on a^er open fractures. Clin Orthop Relat Res. 2005;433:205–11.
* Patzakis MJ, Wilkins J. Factors influencing infec*on rate in open fracture wound. Clin Orthop Relat Res. 1989;243:36–40.

13. The Host
• Waldvogel classifica*on 1970
• Cierny-Mader classifica*on

14. Treatment of Open Fractures
1. Immediate debridement and irriga*on,
including repeated debridement and irriga*on
of type III fractures at 24–48 h intervals
2. An*bio*c therapy
3. Secure fracture stability
4. Wound coverage, either by delayed primary
closure or by local or free flaps
5. Early cancellous bone gra^ing
6. Make an early decision on amputa*on.

15. Post-Opera*ve Infec*on in Closed
Fractures Treated with Internal
Fixa*on
• The aim:
– avoid a chronic infec*on.
– avoid infected pseudarthrosis.
• Early and late.
– 4 weeks.

16. • Within 4 weeks:
– radical so^-*ssue debridement, harves*ng of
*ssue biopsies for culture and wound closure.
– Stable??.
• A^er 4 weeks:
– The implant should be removed.
– Ext fixa*on.
– staph. *

17. • a large dead space that needs to be managed
effec*vely to prevent recurrence of infec*on.
• The management of the dead space in this
selng includes
– closed irriga*on systems,
– local so^ *ssue flaps,
– vascularized free flaps,
– a variety of methods for local an*bio*c delivery

20. Prosthe*c Joint Infec*ons
• A prosthe*c joint infec*on (PJI) is any
infec*on due to bacteria or fungi in a total or
hemi-arthroplasty.
• Classifica*on:
– Stage I infec*on (acute infec*on)
– Stage II (delayed infec*on)
– Stage III presents as a haematogenous
* Coventry MB. Treatment of infec*ons occurring in total hip surgery. Orthop Clin North Am. 1975;10(4):991–1003.
* Fitzgerald RH, Nolan DR, Ilstrup DM, Van Scoy RE, Washington JA, Coventry MB. Deep wound sepsis following total hip arthroplasty. J
Bone Joint Surg Am. 1977;59:847–55.

21. • acute PJI becomes chronic a^er few weeks
– Stage I PJI: An acute post-opera*ve infec*on that
occurs <4 weeks a^er implanta*on.
– Stage II PJI: A chronic infec*on that occurs >4
weeks a^er implanta*on.
– Stage III PJI: A haematogenous infec*on.

22. Diagnosis:

23. Clinical

24. Image

26. Management:
• The different op*ons for treatment of a PJI is:
– so^ *ssue debridement,
– one-stage or two-stage prosthe*c revision,
– permanent resec*on arthroplasty (Girdlestone) or
arthrodesis,
– an*microbial suppression therapy,
– amputa*on.

29. Take home message
• Treat early.
• Don’t fix suspicious bone.
• Early loosening means infec*on.
Good luck