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Treating infections

Tuesday, June 05, 2018

Doctors are often blamed for orthopaedic infections, but the patient’s health and immunity also matter, says Dr Naresh Shivdasani

Advances in surgery have increased the number of planned and emergency surgeries. More and more fractures are fixed, more joints replaced and surgeries are being done on immuno-compromised patients (HIV positive, diabetics, alcoholics, rheumatoid arthritis patients).When all goes well, we have  happy patients and happy surgeons.

Patients who have a bone and joint infection have to undergo multiple surgeries and generate large medical bills. Immense suffering is the result. Though every precaution is taken to prevent infection during and after surgery, about one percent can get infected, even in the best set-ups.

In a road accident, there can be complex injuries, crushing wounds and poor blood circulation. Contamination from mud, gravel and other foreign materials add to the chances of infection. Any open wound with a fracture should be treated as early as possible in a hospital setting. Any infection in a joint damages the cartilage irreversibly. This leads to loss of movement, often causing the joint to get completely fused.

Signs and symptoms

Pain at the site of infection, swelling, redness, loss of function are seen early at the onset of infection.


X-rays, CT scans, MRIs and Radio-active bone scans help in the diagnosis. Routine and specialised blood tests are done. The site of the wound must be inspected. Bacterial cultures swabs should be taken for determining the causative organism. Sometimes fungal cultures may need to be done. Hospitalisation is a must.


In an acute infection, the wound must be re-opened and a thorough cleaning under general anaesthesia be done. All dead tissue must be excised, preserving blood supply and nerve supply. Any implant should be removed as its presence prevents the infection from subsiding. If the fracture has not healed an external fixator or similar device must be used to hold the fracture in place. The Russian technique, popularised by Ilizarov, can be used if the facilities are available. The patient may need a long period of rehabilitation till the limb is functional again. Higher antibiotics are also prescribed for prolonged periods. Antibiotic impregnated bone cement can be used at the site of infection during debridement of the wound.

In children, the consequences can be far worse. The growing ends of the bones, (epiphyses) can be damaged by the collection of infected material around the bones. The pus should  be drained immediately to prevent further damage. Any dead bone must be removed. Appropriate antibiotics are used in adequate doses. There could be severe limb length discrepancy once the epiphyses are damaged. Any sequelae need to be managed once the infection is under control.


Tuberculosis of the skeletal system is also known. Commonly found to infect the spine, in children. It can lead to spinal deformities, stunted growth and paralysis, if the spinal cord is compressed.Skeletal tuberculosis (TB) is a secondary infection, borne by the blood and lodged in the bone.

Accurate diagnosis can be made with the use of X-rays, MRIs or CT scans. It would be always better if the infected material can be aspirated to send for culture and sensitivity, especially in the days of resistant TB. Early knowledge of the resistant strains would save time, money and bone tissue. Sometimes surgery is done to correct deformities and also to remove infected material.

The treatment of bone TB is prolonged, as much as a year-and-a-half. Regular follow-ups are needed to make sure that the patient is taking treatment in proper doses. Many leave the medication midway through treatment, with disastrous consequences.

In short, bone infection is a serious problem leading to prolonged suffering and permanent disability. Every effort must be made to prevent it. The patient's general health and immunity are extremely important to overcome the invading bacteria. Often the doctor is blamed for the infection, but patient factors also contribute to the prevalence and spread of bone and joint infections.

If you need advice, write to Dr Naresh Shivdasani at; he will answer queries in this column.

Dr Naresh Shivdasani (D.Orth, M.S. (Orth) is a Senior Orthopaedic Surgeon, with interest in Acupuncture and Spinal Manipulation. He believes that most disease originates from stress and lifestyle issues.

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