OR3.3 | Operative Source Control Assistance — Summary & Reflection

KEY TAKEAWAYS

Operative source control is the definitive management of established musculoskeletal infection when antibiotics cannot reach the infected focus. The three procedures — abscess drainage (evacuate pus, debride necrotic tissue, irrigate, manage open wound), sequestrectomy/saucerisation (remove all avascular dead bone, create open vascular cavity, manage dead space), and arthrotomy (evacuate joint pus, copious lavage, drain, early physiotherapy) — each address a specific pathological problem and must be matched to the correct indication. The team-assist member's critical contributions are: confirming the operative specimen is collected before irrigation, maintaining instrument counts, managing retraction safely, and recognising post-operative complications (wound haematoma, neurovascular compromise, recurrent sinus). Completeness of sequestrectomy determines outcome — any residual avascular bone perpetuates infection and causes recurrence. In the hip, urgency of arthrotomy is driven by the risk of avascular necrosis from raised intra-articular pressure on the lateral epiphyseal vessels.

REFLECT

You are called to review a 16-year-old who underwent sequestrectomy of the left femur three weeks ago. He was discharged on oral antibiotics but now presents with recurrence of purulent discharge from the wound and X-ray showing a small residual dense bone fragment at the operative site. He is afebrile and his CRP is 35 mg/L. Reflect on why this recurrence has occurred, what should have been done intra-operatively to prevent it, and how you would manage the situation now. What would you tell this patient and his family, and how does this clinical failure underscore the principle that completeness of debridement is the sole determinant of surgical success in chronic osteomyelitis?