Bone and Joint InfectionsBone and Joint Infections

OutlineOutline

Acute OsteomyelitisAcute Osteomyelitis

Subacute OsteomyelitisSubacute Osteomyelitis

Chronic OsteomyelitisChronic Osteomyelitis

Septic ArthritisSeptic Arthritis

What is OsteomyelitisWhat is Osteomyelitis??

It is Inflammatory process of the bone andIt is Inflammatory process of the bone and

its structures secondary to infectionits structures secondary to infection

Factors Affecting the development of Factors Affecting the development of OsteomyelitisOsteomyelitis::

Host Factors (i.e. immunity status)Host Factors (i.e. immunity status)

Local Factors (e.g. damaged tissue, Local Factors (e.g. damaged tissue, foreign material, bone structureforeign material, bone structure……))

Organism involved (e.g. virulency of Organism involved (e.g. virulency of the organism)the organism)

Acute OsteomyelitisAcute Osteomyelitis

Types of Acute Types of Acute OsteomyelitisOsteomyelitis

Hematogenous osteomyelitis:Hematogenous osteomyelitis:

Bacterial seeding from the bloodBacterial seeding from the blood . .occurs primarily in childrenoccurs primarily in children . .

The most common site is the rapidly growing and highly vascular The most common site is the rapidly growing and highly vascular metaphysis of growing bonesmetaphysis of growing bones . .

Despite its name, may have a slow clinical development and Despite its name, may have a slow clinical development and insidious onsetinsidious onset..

Direct or contiguous inoculation Direct or contiguous inoculation osteomyelitis:osteomyelitis:

Direct contact of the tissue and bacteria during trauma or surgery, Direct contact of the tissue and bacteria during trauma or surgery, spread from a contiguous focus of infectionspread from a contiguous focus of infection . .ClinicallyClinically::More localized than those of hematogenous osteomyelitisMore localized than those of hematogenous osteomyelitis Tend to involve multiple organismsTend to involve multiple organisms..

Risk factorsRisk factors::

Diabetes mellitusDiabetes mellitusSickle cell diseaseSickle cell diseaseAcquired immune deficiency syndrome (AIDS)Acquired immune deficiency syndrome (AIDS)IV drug abuseIV drug abuseAlcoholismAlcoholismChronic steroid useChronic steroid use ImmunosuppressionImmunosuppressionChronic joint diseaseChronic joint disease . .

The presence of a prosthetic orthopedic deviceThe presence of a prosthetic orthopedic device Any recent orthopedic surgeryAny recent orthopedic surgery Open fractureOpen fracture..

EpidemiologyEpidemiology Incidence is higher in developing countries Incidence is higher in developing countries

compared to developed ones.compared to developed ones. Morbidity results from its complications.Morbidity results from its complications. Male-to-female ratio is approximately 2:1Male-to-female ratio is approximately 2:1 Acute hematogenous osteomyelitis is Acute hematogenous osteomyelitis is

primarily a disease in children.primarily a disease in children. Spinal osteomyelitis is more common in Spinal osteomyelitis is more common in

persons older than 45 yearspersons older than 45 years..

Causative OrganismsCausative Organisms

Acute hematogenous osteomyelitisAcute hematogenous osteomyelitis: :

Newborns (younger than 4 mo): Newborns (younger than 4 mo): S .aureusS .aureus, , EnterobacterEnterobacter species, and group A and B species, and group A and B StreptococcusStreptococcus species species

Children (aged 4 mo to 4 y): Children (aged 4 mo to 4 y): S. aureusS. aureus, , group A group A StreptococcusStreptococcus species, species, Haemophilus influenzaeHaemophilus influenzae, and , and EnterobacterEnterobacter species species

ContCont……

Children, adolescents (aged 4 y to Children, adolescents (aged 4 y to adult):adult):S .aureusS .aureus (80%), group A (80%), group A

StreptococcusStreptococcus species, species, H. influenzaeH. influenzae, and , and EnterobacterEnterobacter species species

Adult: Adult: S .aureusS .aureus and occasionally and occasionally EnterobacterEnterobacter or or StreptococcusStreptococcus species species

Causative OrganismsCausative OrganismsDirect osteomyelitisDirect osteomyelitis: :

Generally: Generally: S aureusS aureus, , EnterobacterEnterobacter species, species, and and PseudomonasPseudomonas species . species .

Puncture wound through an athletic shoe: Puncture wound through an athletic shoe: S aureusS aureus and and PseudomonasPseudomonas species. species.

Sickle cell disease - Sickle cell disease - S aureusS aureus and and SalmonellaeSalmonellae species. species.

PathologyPathology

Inflammation:Inflammation: Suppuration: Suppuration:

Volkmann canals, subperiosteal abcess, spread along the Volkmann canals, subperiosteal abcess, spread along the shaft, re-enter the bone or burst into the soft tissueshaft, re-enter the bone or burst into the soft tissue

Neonates: extends to the epiphysisNeonates: extends to the epiphysis Older children: confined to the metaphysis. Older children: confined to the metaphysis.

NecrosisNecrosis New-bone formationNew-bone formation

Bone thickens to form an involucrum enclosing the Bone thickens to form an involucrum enclosing the infected tissue an sequestra.infected tissue an sequestra.

Perforation may occur (cloacae) and become converted Perforation may occur (cloacae) and become converted to chronic osteomyelitisto chronic osteomyelitis

ResolutionResolution

Bone destruction of head of 2Bone destruction of head of 2ndnd metatarsal metatarsalwith periosteal new bone formation with periosteal new bone formation characteristic of osteomyelitischaracteristic of osteomyelitis  

ComplicationsComplications:: Spread:Spread:

To the joints: septic arthritisTo the joints: septic arthritis

To other bones: metastatic osteomyelitis To other bones: metastatic osteomyelitis

Growth disturbance and deformities.Growth disturbance and deformities. Persistent infection.Persistent infection. Fracture. Fracture. Loosening of the prosthetic implant .Loosening of the prosthetic implant . Overlying soft-tissue cellulitis.Overlying soft-tissue cellulitis.

Clinical ApproachClinical Approach

HistoryHistory

Physical examinationPhysical examination

InvestigationsInvestigations

HistoryHistory Hematogenous osteomyelitis: usually slow insidious Hematogenous osteomyelitis: usually slow insidious

progression of symptoms. progression of symptoms. Direct osteomyelitis: generally more localized, with Direct osteomyelitis: generally more localized, with

prominent signs and symptoms. prominent signs and symptoms. General symptoms of osteomyelitis include the following:General symptoms of osteomyelitis include the following:

Hematogenous long-bone osteomyelitis Hematogenous long-bone osteomyelitis 1.1. Abrupt onset of high fever (fever is present in only 50% of neonates Abrupt onset of high fever (fever is present in only 50% of neonates

with osteomyelitis) with osteomyelitis) 2.2. Fatigue Fatigue 3.3. Irritability Irritability 4.4. Malaise Malaise 5.5. Restriction of movement .Restriction of movement .6.6. Local edema, erythema, and tenderness Local edema, erythema, and tenderness

Hematogenous vertebral osteomyelitis Hematogenous vertebral osteomyelitis 1.1. Insidious onset Insidious onset 2.2. History of an acute bacteremic episode History of an acute bacteremic episode 3.3. May be associated with contiguous vascular insufficiency May be associated with contiguous vascular insufficiency 4.4. Local edema, erythema, and tenderness Local edema, erythema, and tenderness

In Infants: History of birth difficulty, umbilical artery In Infants: History of birth difficulty, umbilical artery catheterization, other sites. catheterization, other sites.

Physical examinationPhysical examination

Findings at physical examination may Findings at physical examination may include the followinginclude the following::

1.1. Fever (present in only 50% of neonates) .Fever (present in only 50% of neonates) .

2.2. Edema .Edema .

3.3. Warmth .Warmth .

4.4. Fluctuance .Fluctuance .

5.5. Tenderness to palpation .Tenderness to palpation .

6.6. Reduction in the use of the extremity .Reduction in the use of the extremity .

InvestigationsInvestigations

1.1. Lab studiesLab studies

2.2. Radiological studiesRadiological studies

Lab studiesLab studies

CBC: leucocytosisCBC: leucocytosis

The C-reactive protein level usually is elevated The C-reactive protein level usually is elevated (nonspecific but more useful than ESR). (nonspecific but more useful than ESR).

ESR usually is elevated (90%) nonspecific. ESR usually is elevated (90%) nonspecific.

Aspiration of the pus from the subperiosteal Aspiration of the pus from the subperiosteal abscess and culture, and test sensitivity for abscess and culture, and test sensitivity for antibiotics antibiotics

Blood culture results are positive in only 50% of Blood culture results are positive in only 50% of patients with hematogenous osteomyelitis.patients with hematogenous osteomyelitis.

Radiological studiesRadiological studiesX-RayX-Ray::

First sign is soft-tissue edema at 3-5 days First sign is soft-tissue edema at 3-5 days after infection. after infection.

Bony changes are not evident for 14-21 Bony changes are not evident for 14-21 days:days:

1.1. early radiographic signs of refraction of the early radiographic signs of refraction of the metaphysis and periosteal new bone formation metaphysis and periosteal new bone formation

2.2. increasing ragged if treatment is delayedincreasing ragged if treatment is delayed

3.3. sclerosis and thickening of the bone at healing sclerosis and thickening of the bone at healing

Approximately 40-50% focal bone loss is Approximately 40-50% focal bone loss is necessary to cause detectable lucency on necessary to cause detectable lucency on plain films. plain films.

Plain-film radiograph Plain-film radiograph showing osteomyelitis of the showing osteomyelitis of the second metacarpal (arrow). second metacarpal (arrow). Periosteal elevation, cortical Periosteal elevation, cortical disruption and medullary disruption and medullary involvement are presentinvolvement are present..

The above X-ray of the The above X-ray of the right ankle of a 10-right ankle of a 10-year-old boy shows year-old boy shows lucency in the tibial lucency in the tibial metaphysis secondary metaphysis secondary to acute hematogenous to acute hematogenous osteomyelitis (AHO)osteomyelitis (AHO)..

The above X-ray of the left ankle of a 10-year-old boy shows lucency in the tibial metaphysis secondary to acute hematogenous osteomyelitis (AHO).

Here is an X-ray of an Here is an X-ray of an AHO lesion extending AHO lesion extending into the growth plateinto the growth plate..

Radiological studiesRadiological studies MRI :MRI :Early detection and surgical localization of Early detection and surgical localization of osteomyelitisosteomyelitis . .

Sensitivity ranges from 90-100%Sensitivity ranges from 90-100% . . Radionuclide bone scanning : Radionuclide bone scanning : A 3-phase bone scan with technetium A 3-phase bone scan with technetium 99m is probably the initial imaging 99m is probably the initial imaging modality of choicemodality of choice

Show increase activity but it is a non Show increase activity but it is a non specific sign of inflamationspecific sign of inflamation..

This MRI sagittal section shows the This MRI sagittal section shows the same AHO lesions with the right lesion same AHO lesions with the right lesion extending into the growth plateextending into the growth plate..

Bone scans, both anterior (A) and lateral (B), Bone scans, both anterior (A) and lateral (B), showing the accumulation of radioactive showing the accumulation of radioactive tracer at the right ankle (arrow). This focal tracer at the right ankle (arrow). This focal accumulation is characteristic of accumulation is characteristic of osteomyelitisosteomyelitis..

Radiological studiesRadiological studies

CT scan (spinal vertebral lesions, complex CT scan (spinal vertebral lesions, complex anatomy: pelvis, sternum, and calcaneus)anatomy: pelvis, sternum, and calcaneus)UltrasoundUltrasound In children with acute osteomyelitisIn children with acute osteomyelitis . .

May demonstrate changes as early as 1-2 days after May demonstrate changes as early as 1-2 days after onset of symptomsonset of symptoms . .

Abnormalities include soft tissue abscess or fluid Abnormalities include soft tissue abscess or fluid collection and periosteal elevationcollection and periosteal elevation . .

Ultrasonography allows for ultrasound-guided Ultrasonography allows for ultrasound-guided aspirationaspiration . .

It does not allow for evaluation of bone cortexIt does not allow for evaluation of bone cortex

DiagnosisDiagnosisDiagnosis requires 2 of the 4 following Diagnosis requires 2 of the 4 following criteriacriteria::

◦ Purulent material on aspiration of Purulent material on aspiration of affected bone. affected bone.

◦ Positive findings of bone tissue or Positive findings of bone tissue or blood culture. blood culture.

◦ Localized classic physical findings of Localized classic physical findings of bony tenderness, with overlying soft-bony tenderness, with overlying soft-tissue erythema or edema. tissue erythema or edema.

◦ Positive radiological imaging study.Positive radiological imaging study.

TreatmentTreatment

Principles of treatmentPrinciples of treatment::

1.1. Analgesia an general supportive measures.Analgesia an general supportive measures.

2.2. Rest of the affected partRest of the affected part

3.3. Antibiotic treatment.Antibiotic treatment.

4.4. Surgical eradication of pus and necrotic tissue.Surgical eradication of pus and necrotic tissue.

TreatmentTreatment

Antibiotic treatmentAntibiotic treatment::

Start with IV antibiotics for 1-2 weeks then oral for 3-Start with IV antibiotics for 1-2 weeks then oral for 3-6 weeks6 weeks..

Take cultures to detect the organism and its Take cultures to detect the organism and its sensitivity patternsensitivity pattern..

Start empirical treatment before the results came Start empirical treatment before the results came back, then modify it according to the resultsback, then modify it according to the results..

TreatmentTreatment

Antibiotic choicesAntibiotic choices::

Older children and adults (staph infection): fluloxacillin and Older children and adults (staph infection): fluloxacillin and fusidic acidfusidic acid..MRSA: VancomycinMRSA: Vancomycin

Children younger than 4 year-old or those with gram Children younger than 4 year-old or those with gram negative organisms: 3negative organisms: 3rdrd generation cephalosporins generation cephalosporins..

Heroin addicts and immuno-compromised patients: more Heroin addicts and immuno-compromised patients: more specific antibioticsspecific antibiotics . .

ContCont……

Sickle cell anemia and osteomyelitis: fluoroquinolone antibiotic Sickle cell anemia and osteomyelitis: fluoroquinolone antibiotic (not in children). A 3(not in children). A 3rdrd cephalosporin (eg, ceftriaxone) is an cephalosporin (eg, ceftriaxone) is an

alternative choicealternative choice . .

Nail puncture occurs through an athletic shoe (Nail puncture occurs through an athletic shoe (S aureusS aureus and and Pseudomonas aeruginosa)Pseudomonas aeruginosa): ceftazidime or cefepime. : ceftazidime or cefepime.

Ciprofloxacin is an alternative treatmentCiprofloxacin is an alternative treatment..

Trauma (Trauma (S aureusS aureus, coliform bacilli, and , coliform bacilli, and Pseudomonas Pseudomonas aeruginosaaeruginosa): nafcillin and ciprofloxacin. Alternatives include ): nafcillin and ciprofloxacin. Alternatives include vancomycin and a 3rd cephalosporin with antipseudomonal vancomycin and a 3rd cephalosporin with antipseudomonal

activityactivity..

TreatmentTreatmentDrainageDrainage::

Subperiosteal abscessSubperiosteal abscess Pyrexia and local tenderness more than Pyrexia and local tenderness more than

24 hour after adequate antibiotic 24 hour after adequate antibiotic treatment.treatment.

Removal of prosthetic implantsRemoval of prosthetic implants::If they become unstable after a traumaIf they become unstable after a trauma..

Or intractable infection following joint Or intractable infection following joint replacementreplacement..

PreventionPrevention

Improve immunity.Improve immunity.

Post-traumatic infection (regular wound dressing for Post-traumatic infection (regular wound dressing for established infection):established infection):

1.1. Debridement of open fractures.Debridement of open fractures.2.2. Stabilization of fractures.Stabilization of fractures.3.3. Antibiotics.Antibiotics.4.4. Closure of exposed bone surfaces.Closure of exposed bone surfaces.

Postoperative infection:Postoperative infection:

1.1. Cleanest possible surgical environment.Cleanest possible surgical environment.2.2. Careful haemostasis.Careful haemostasis.3.3. Suction drainage.Suction drainage.4.4. Prophylactic antibiotics in high risk surgeries.Prophylactic antibiotics in high risk surgeries.

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