BONE AND JOINT INFECTIONS

1. BONE AND JOINT INFECTIONS JOSE FERNANDO SYQUIA, MD SECTION OF ORTHOPEDIC SURGERY DEPARTMENT OF SURGERY

2. OSTEOMYELITIS • Definition: • Inflammation of bone caused by infection • Modes of transmission: • Blood borne • Contiguity • Direct invasion • Open wound • Innoculation

3. OSTEOMYELITIS • Types: • Acute hematogenous osteomyelitis • Subacute osteomyelitis • Chronic osteomyelitis

4. ACUTE HEMATOGENOUS OSTEOMYELITIS • By blood borne organisms • Children commonly affected • Staphylococcus aureus – most common • Located at metaphysis • Long-term morbidity is > 25%

5. Pathology: Inflammation Suppuration Necrosis New bone formation Resolution Clinical findings: Pain Fever Inflammation Loss of function Soft tissue abscess ACUTE HEMATOGENOUS OSTEOMYELITIS

6. 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

7. ACUTE HEMATOGENOUS OSTEOMYELITIS • Treatment: • Antibiotics • IV for 6 weeks • Immobilization • Surgical drainage • Abscess • Debridement of infected tissues • Failure of nonoperative treatment

8. ACUTE HEMATOGENOUS OSTEOMYELITIS

9. ACUTE HEMATOGENOUS OSTEOMYELITIS • Complications: • Septic arthritis • Growth disturbance • Chronic osteomyelitis

10. POST-TRAUMATIC AND POSTOPERATIVE OSTEOMYELITIS • Infected open fracture • Usual cause of osteomyelitis in adults • Staphylococcus aureus – most common

11. 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

12. Laboratory findings: Leucocytosis Elevated ESR and CRP Positive cultures Treatment: Debridement Antibiotics

13. SUBACUTE OSTEOMYELITIS • Due to: • Partially treated acute osteomyelitis • Infection of fracture hematoma • Can cross the physis • Commonly affects femur or tibia

14. 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

15. CHRONIC OSTEOMYELITIS • Due to: • Inappropriately treated acute osteomyelitis • Trauma (accidental or surgical) • Soft tissue spread • Epidermoid carcinoma • Fistulous tracts may develop into these

16. CHRONIC OSTEOMYELITIS • Pseudomonas • Seen with IV drug abusers • Salmonella • Seen with sickle cell disease • Staphylococcus aureus, G- rods, anaerobes • Common organisms

17. CHRONIC OSTEOMYELITIS • Clinical findings: • Draining sinus • Periods of quiescence and acute exacerbations (flare) • Pain, pyrexia, redness and tenderness during exacerbation

18. 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

19. Definition: Joint infection Common in infants and children Adults: Rheumatoid arthritis IV drug abuse Pseudomonas Sexually active Gonococcal arthritis PYOGENIC ARTHRITIS

20. PYOGENIC ARTHRITIS • Modes of transmission: • Hematogenous • Local spread from osteomyelitis • Proximal femur • Proximal humerus • Radial neck • Distal fibula • Puncture wound • Open wound

21. PYOGENIC ARTHRITIS

22. Clinical findings: Red, hot swollen joint Acute pain Fever and chills Constitutional signs of infection Radiographic findings: Widening of joint space Soft tissue swelling PYOGENIC ARTHRITIS

23. 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

24. TUBERCULOUS ARTHRITIS • Caused by Mycobacterium tuberculosis • Joint involved by hematogenous spread • Lung or intestines • A chronic inflammatory process • Spine and lower extremities usually involved

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

26. 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

27. TUBERCULOUS ARTHRITIS • Treatment: • Anti-TB medications for 6-12 months • Debridement • Rest, traction and splintage

28. 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

29. 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

30. Laboratory findings: Elevated ESR (+) Mantoux test Treatment: Anti-TB chemotherapy for 6-12 months Brace Surgery TUBERCULOSIS OF THE SPINE

31. 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

32. Types: Pyogenic spondylitis Discitis Usually staphylococcus Clinical findings: Pain Muscle spasm Restricted spinal movement PYOGENIC SPINAL INFECTION

33. 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