BONE AND JOINT INFECTIONS

JOSE FERNANDO SYQUIA, MDSECTION OF ORTHOPEDIC SURGERY

DEPARTMENT OF SURGERY

OSTEOMYELITIS

• Definition:– Inflammation of bone caused by infection

• Modes of transmission:– Blood borne– Contiguity– Direct invasion

• Open wound

• Innoculation

OSTEOMYELITIS

• Types:

– Acute hematogenous osteomyelitis

– Subacute osteomyelitis

– Chronic osteomyelitis

ACUTE HEMATOGENOUS OSTEOMYELITIS

• By blood borne organisms

• Children commonly affected

• Staphylococcus aureus – most common

• Located at metaphysis

• Long-term morbidity is > 25%

ACUTE HEMATOGENOUS OSTEOMYELITIS

• Pathology:– Inflammation– Suppuration– Necrosis– New bone

formation– Resolution

• Clinical findings:– Pain– Fever – Inflammation – Loss of function– Soft tissue abscess

ACUTE HEMATOGENOUS OSTEOMYELITIS

• Radiographic findings:– Soft tissue swelling– Demineralization

(10-14 days)– Sequestrum and

involucrum later

• Laboratory findings:– Elevated WBC– Elevated ESR,

CRP– (+) blood culture

ACUTE HEMATOGENOUS OSTEOMYELITIS

• Treatment:– Antibiotics

• IV for 6 weeks– Immobilization– Surgical drainage

• Abscess• Debridement of infected tissues• Failure of nonoperative treatment

ACUTE HEMATOGENOUS OSTEOMYELITIS

AGE ORGANISM INITIAL MEDS

Newborn Staphylococcus aureus

Grp A or B streptococcus

Enterobacteriaceae

PRSP + third generation cephalosporin

Child < 4 years H. influenzae

Streptococci

Staphylococcus aureus

Cefuroxime or third generation cephalosporin

Child > 4 years Staphylococcus aureus

Steptococci

H. influenzae

PRSP or first generation cephalosporin

Adult Staphylococcus aureus

Enterobacteriaceae

Streptococcus species

PRSP or first generation cephalosporin

ACUTE HEMATOGENOUS OSTEOMYELITIS

• Complications:

– Septic arthritis

– Growth disturbance

– Chronic osteomyelitis

POST-TRAUMATIC AND POSTOPERATIVE OSTEOMYELITIS

• Infected open fracture

– Usual cause of osteomyelitis in adults

– Staphylococcus aureus – most common

• Postoperative infection

– Predisposing factors:

• Debility

• Chronic disease

• Previous infection

• Steroid therapy

• Long operations

• Use of foreign materials

• Clinical findings:

– Fever

– Pain and swelling over fracture site

– Wound is inflamed

– Discharge noted

• Laboratory findings:

– Leucocytosis

– Elevated ESR and CRP

– Positive cultures

• Treatment:

– Debridement

– Antibiotics

SUBACUTE OSTEOMYELITIS

• Due to:– Partially treated acute osteomyelitis– Infection of fracture hematoma

• Can cross the physis

• Commonly affects femur or tibia

• Clinical findings:– Painful limp– No systemic or even local signs or symptoms

• Radiographic findings:– May mimic tumors– Brodie’s abscess

• Localized radiolucency usually in the metaphysis of long bones

• Laboratory findings:– WBC count and cultures may be normal– ESR may be elevated

• Treatment:– Surgical curettage or debridement– Antibiotics for 6 weeks

CHRONIC OSTEOMYELITIS

• Due to:– Inappropriately treated acute osteomyelitis– Trauma (accidental or surgical)– Soft tissue spread

• Epidermoid carcinoma– Fistulous tracts may develop into these

CHRONIC OSTEOMYELITIS

• Pseudomonas– Seen with IV drug abusers

• Salmonella– Seen with sickle cell disease

• Staphylococcus aureus, G- rods, anaerobes– Common organisms

CHRONIC OSTEOMYELITIS

• Clinical findings:– Draining sinus– Periods of quiescence and acute

exacerbations (flare)– Pain, pyrexia, redness and tenderness during

exacerbation

• Radiographic findings:– Sequestrum– Involucrum

• Laboratory findings:– May be normal, unless in acute exacerbation

• Treatment:– Surgical debridement– IV antibiotics based on cultures– Coverage of soft tissue defects– Amputations

PYOGENIC ARTHRITIS

• Definition:– Joint infection

• Common in infants and children

• Adults:– Rheumatoid

arthritis– IV drug abuse

• Pseudomonas – Sexually active

• Gonococcal arthritis

PYOGENIC ARTHRITIS

• Modes of transmission:– Hematogenous– Local spread from osteomyelitis

• Proximal femur• Proximal humerus• Radial neck• Distal fibula

– Puncture wound– Open wound

PYOGENIC ARTHRITISAGE ORGANISM INITIAL MEDS

< 3 months Staphylococcus aureus

Enterobacteriaceae

Group B streptococcus

PRSP + third generation cephalosporin

3 months – 6 yrs Staphylococcus aureus

H. influenzae

Streptococci

Enterobacteriaceae

(PRSP or first generation cephalosporin) + third generation cephalosporin

Adult Staphylococcus aureus

Group A streptococci

Enterobacteriaceae

[(PRSP or first gen cephalosporin) + (APAG or Ciprofloxacin)] or Timentin or Piperacillin Tazobactam or Unasyn

Joint replacement Staphylococcus epidermidis

Staphylococcus aureus

Enterobacteriaceae

Pseudomonas

Vancomycin + ciprofloxacin or aztreonam or APAG

PYOGENIC ARTHRITIS

• Clinical findings:– Red, hot swollen

joint– Acute pain– Fever and chills– Constitutional signs

of infection

• Radiographic findings:– Widening of joint

space– Soft tissue swelling

• Laboratory findings:– Elevated WBC– Elevated ESR and CRP– Blood cultures– Synovial fluid analysis

• Treatment:– Establish the diagnosis– Surgical drainage or open drainage– Antibiotics– Splinting the joint

• Complications:– Dislocation– Destruction of epiphysis– Ankylosis

TUBERCULOUS ARTHRITIS

• Caused by Mycobacterium tuberculosis

• Joint involved by hematogenous spread– Lung or intestines

• A chronic inflammatory process

• Spine and lower extremities usually involved

TUBERCULOUS ARTHRITIS

• Clinical findings:– Swollen joint– Painful joint– Muscle wasting– Limitation of movement– May have constitutional signs of TB– Later, stiff and deformed joint

TUBERCULOUS ARTHRITIS

• Laboratory findings:– Positive Mantoux

test– Elevated ESR– Synovial fluid

analysis• AFB• Rice bodies• Positive cultures

• Radiographic findings:– Subchondral

osteoporosis– Cystic changes– Joint space

narrowing

TUBERCULOUS ARTHRITIS

• Treatment:– Anti-TB medications for 6-12 months – Debridement– Rest, traction and splintage

TUBERCULOSIS OF THE SPINE

• Most common site of skeletal TB• Pott’s disease

• Pathology:– Blood borne infection– Vertebral body involved– Destruction and caseation necrosis– Spread to disc space and next vertebra– Vertebral bodies collapse– Cold abscess form

TUBERCULOSIS OF THE SPINE

• Clinical findings:– Long-standing

history of poor health

– Backache– Abscess– Neurologic deficit– Kyphosis– Tenderness – Muscle spasm

• Radiographic findings:– Paravertebral

abscess– Collapse of

vertebra– Deformity

TUBERCULOSIS OF THE SPINE

• Laboratory findings:– Elevated ESR– (+) Mantoux test

• Treatment:– Anti-TB

chemotherapy for 6-12 months

– Brace– Surgery

• Pott’s paraplegia– Spinal cord compressed by:

• Inflammatory material• Bone or disc• Fibrosis

– Signs of paraplegia • Early-onset paraparesis

–ADSF with recovery in majority• Late-onset paraparesis

–Due to deformity, disease reactivation, vascular problem

PYOGENIC SPINAL INFECTION

• Types:– Pyogenic

spondylitis– Discitis

• Usually staphylococcus

• Clinical findings:– Pain – Muscle spasm– Restricted spinal

movement

• Radiographic findings:– Narrowing of disc space– Destruction of vertebral body– Now bone formation in later cases

• Laboratory findings:– Elevated ESR– Needle biopsy may be needed

• Treatment:– Bed rest– IV antibiotics for 4-6 weeks– Spinal brace