Treating a chronic orthopaedic infection of any kind, in any patient, can be a challenge for even the most skilled surgeon. If you are unfortunate enough to be saddled with this diagnosis, you would want to have an experienced senior surgeon managing your condition, working together with dedicated infectious disease specialists, pharmacists, and microbiologists. At the Limb Reconstruction Centre at MQ Health, we are indeed fortunate to have assembled a cohesive team of other specialists and medical professionals who act in concert together with us to deal with these unique problems, using the latest advances and most sophisticated techniques currently available.
Ultimately, however, chronic orthopaedic infection is best considered a surgical disease, and these procedures can be technically demanding and difficult. The two most important surgical principles that govern treatment of chronic infection include an atraumatic approach, and complete removal of all devitalized tissue and foreign material. Despite continuing advances in medical science, the quality of this process, called surgical debridement, remains the most critical factor in the successful management of chronic orthopaedic infections. Those of us with a genuine interest in the management of this difficult problem recognize that attention to detail, gentle soft tissue handling, and a systematic approach are all critical to maximise the potential for a successful outcome.
When cases with a chronic or recurrent infection are referred to a tertiary unit such as the Limb Reconstruction Centre at MQ Health, it is very beneficial to objectively analyse each case and try to determine why initial treatment failed. There are in fact only a limited number of defined reasons why treatment fails, though it appears a combination of factors may often be responsible: resistant organisms, inadequate antibiotic coverage, deficient soft tissue coverage, and immune compromised hosts all play a role. But in the vast majority of cases incomplete debridement appears to be a very important factor, and this is almost certainly the most significant single factor contributing to treatment failure.
What characteristics distinguish the technique of a surgeon who has mastered debridement of these chronic infections from those surgeons who have not? Although there are certain specific technical considerations that help assure debridement has been full and complete, in many instances the distinguishing factors appear to be more likely the result of cognitive aspects. While this may be considered an intangible, it is quite simply a reflection of the surgeon’s knowledge, experience, preparation, and intuition. Inadequate planning and failure to have a clear outcome in mind is not uncommon. Frequently the treatment failure can be traced back to the inability to achieve an adequate surgical margin, with incomplete debridement. It is subsequently difficult, if not impossible, to determine the specific sequence of events leading to this unfortunate outcome. This may reflect the failure to recognize the full extent of involvement, resulting from suboptimal pre-operative studies, or failure to appreciate the significance of the findings demonstrated Alternatively, it may reflect instead reluctance to debride bone or cartilage completely, perhaps suggesting the treating surgeon does not have the requisite resources, skills, and experience necessary to fully reconstruct the resulting debridement defect. Finally, and perhaps most frequently observed, the incision used and exposure obtained are quite simply too small to allow adequate visualization of the area of interest. This last aspect almost certainly reflects elements common to the other factors just identified, but may be further indicative of a general failure of many orthopaedic surgeons to fully appreciate the difficulty inherent in eradication of an established chronic orthopaedic infection.
These same principles apply equally to chronic infections of all types, including prosthetic joint infections, chronic osteomyelitis, and fracture-related infections, such as an infected non-union. These operative procedures should always be undertaken in a very systematic and ordered fashion, and they are almost certainly done best by surgeons very experienced and accomplished in this challenging area of orthopaedic super-specialization. The surgery can be difficult and more demanding than the vast majority of elective procedures; these procedures clearly benefit from more experience and greater technical skill. Contrary to common practice in many other centres, musculoskeletal sepsis surgery should almost certainly be undertaken by the most experienced surgeons available, not the least experienced, and this is most important with respect to decision making and other cognitive aspects. The specialist surgeons of the Limb Reconstruction Centre at Macquarie University Hospital have tremendous experience in this complex, difficult, and demanding area. We are supported by a dedicated unit of infectious disease specialists and other medical professionals, with the requisite knowledge and clinical judgement that only comes from years of experience. Together, we have the skills, experience, and resources necessary to successfully eradicate chronic orthopaedic infections, even after other specialist surgeons have been unable to achieve success.
