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Treatment for resistant osteoarticular infections

Tractament d’infeccions osteoarticulars resistents a Vall d'Hebron

The concept of resistant osteoarticular infections encompasses all procedures on patients with infections that have not responded to previous medical and surgical treatment. These procedures may be changing prostheses or treatment for chronic osteomyelitis or septic pseudoarthrosis among others. The Musculoskeletal System Septic Pathology Unit also treats many of these patients from the start due to the complexity of their condition.

Description

The different types of resistant osteoarticular infections treated in the unit are:

Osteomyelitis/osteitis of haematogenous origin and which are resistant to medical and surgical treatment:  

  • Symptoms may be acute or subacute and accompanied by pain. Many patients may have fever, tumefaction (swelling of part of the body due to inflammation, tumour or oedema) and erythema (reddening of the skin).
  • Clinical suspicion aids diagnosis and sometimes diagnostic imaging may also be useful. The definitive diagnosis is made by isolating the pathogen microorganism.
  • Treatment is debridement (surgery) and antibiotics to target the microorganism responsible.

 

Chronic osteomyelitis or  septic pseudoarthrosis derived from trauma or surgical interventions. Those resulting from open fractures, typically in the tibia, are often accompanied by loss of bone or the cutaneous covering. Exact incidence rates are not known, but the more exposed the bone has been, the higher the chances of chronic infection.

  • Treatment depends on how badly affected the bone is. If  the total thickness of the bone is not compromised and its length can be maintained, debridement and packing with antibiotic-releasing dressing is sufficient. If it is severely affected and an entire segment of bone needs to be resectioned, or in cases of septic pseudoarthrosis, then bone reconstruction techniques have to be used.
  • Distraction osteogenesis, usually performed via external monolateral or circular fixators, is the most common lower limb reconstruction technique in adults. Other techniques are induced membrane (Masquelet) and microsurgery techniques such as vascularized peroneal reconstruction. 

 

Periprosthetic infections. This type of infection occurs in 1-3% of primary arthroplasty procedures. In some cases, the only obvious symptom may be pain. The presence of a fistula or the isolation of a pathogen microorganism in different samples is used to confirm diagnosis. The most common treatment is to change the prosthesis in two separate procedures.

  • During the first surgery the prosthesis is removed, the entire joint cleaned and a spacer with antibiotic is fitted. The patient is treated with antibiotics for a few weeks.
  • Following this, the new prosthesis is fitted during the second surgery. Despite this, infection reappears in 10-15% of cases. Our unit treats this kind of prosthesis-related resistant infections from all over the country, which is why we are the leading centre in the National Healthcare System (CSUR).

 

Severe treatment-resistant diseases of the soft tissue (necrotizing fasciitis, gangrene). These are extremely unusual lesions and when do they appear they are often fatal. Excessive localized pain may be the only initial symptom, making it very difficult to diagnose at this stage. When diagnosed, aggressive treatment with antibiotics and surgical debridement can have an impact on survival and the need for amputation.  

 

Prevention

Patient-related factors (control of additional diseases or disorders) are very important in the prevention of osteoarticular infection, as are those related to surgery (antibiotic prophylaxis), the presence of implants, and tissue condition (bone and cutaneous covering) amongst others.

This type of infection requires a multidisciplinary team as treatment is very complex.

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