osteomyelitis septic arthritis melih güven, m.d assoc. prof. yeditepe university hospital...
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OsteomyelitisSeptic Arthritis
Melih Güven, M.DAssoc. Prof.
Yeditepe University HospitalDepartment of Orthopaedics and Traumatology
Istanbul
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Learning Objectives
1. Should be able to do the classification of osteomyelitis and septic arthritis
2. Should be able to explain the pathogenesis of osteomyelitis and septic arthritis
3. Should be able to list the possible pathogens of osteomyelitis and septic arthritis due to classification and patient age
4. Should be able to define the laboratory findings of osteomyelitis and septic arthritis
5. Should be able to list the clinical and pathological findings of osteomyelitis and septic arthritis
6. Should be able to list the drugs that are being used for the treatment of different pathogens
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Bone and Joint Infections
OsteomyelitisInfection of the bone and bone marrow
(osteo, myelitis)Mostly bacterial, can be fungal
Septic ArthritisInfection of jointsMostly bacterial, can be fungal and viral
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Osteomyelitis
4
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Osteomyelitis
Well known disease since EgyptiansPre-antibiotic era had 25% mortalitySignificant morbidity/disability worldwide due
to lack of access to careLeading cause for amputationsSignificant cause of pediatric disability
worldwide
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Osteomyelitis
Acute Hematogeneus OsteomyelitisNewbornChildren AdultsSickle Cell AnemiaHemodialysis and iv Drug abused patients
Acute osteomyelitisChronic OsteomyelitisSubacute OsteomyelitisChronic Sclerosing Osteomyelitis
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Osteomyelitis
Microorganisms enter bone (Phagocytosis)
Phagocyte contains the infection
Release enzymes
Lyse bone
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Osteomyelitis
Bacteria escape host defenses by:
Adhering tightly to damage bone
Persisting in osteoblasts
Protective polysaccharide-rich biofilm
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OsteomyelitisPus spreads into vascular channels
Raising intraosseous pressure
Impairing blood flow
Chronic ischemic necrosis and abscess
Separation of large devascularized fragment
(Sequestra)
New bone formation (involucrum)
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Osteomyelitis
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Osteomyelitis
Acute Infiltration of PMNs Congested or thrombosed vessels
Chronic Necrotic bone Absence of living osteocyte Mononuclear cells predominate Granulation & fibrous tissue
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Osteomyelitis
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Osteomyelitis
Acute Hematogeneus OsteomyelitisBone and bone marrow infection caused by blood-borne
organisms commonly in childrenIn children infection starts in metaphysis and epiphysis
especially in lower extremityRadiology
Soft tissue swelling: EarlyBone demineralisation: 10-14 daysSequestra and involucrum : > 2 weeks
Pain, loss of function, fever, elevated WBC, ESR and CRP and positive blood culture
MRI, PET and X ray can be usedCRP is the most sensitive monitor of the course in children
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Osteomyelitis
Acute Hematogeneus OsteomyelitisNewborn(<4 months of age)
S. AureusGr- bacilliGroup B str.Treatment
Treat like sepsisOxacilin+3. generation cephalosporin
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Osteomyelitis
Acute Hematogeneus OsteomyelitisChildren(>4 years of age)
S. AureusGroup A str.H. InfluenzaTreatment
Oxacilin/ vancomycin/ clindamycin3. generation cephalosporin is included wheather Gr- bacilli is
involved
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Osteomyelitis
Acute Hematogeneus OsteomyelitisAdults
S. AureusTreatment
Nafcilin/oxacilin/cefazolin/vancomycin
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Osteomyelitis
Acute Hematogeneus OsteomyelitisSickle Cell Anemia
SalmonellaTreatment
Flouroquinolones/3. generation cephalosporine
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Osteomyelitis
Acute Hematogeneus OsteomyelitisHemodialysis and iv Drug abused patients
S.aureusS. EpidermidisP.AeruginosaTreatment
Vancomycin+ciprofloxacin
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Osteomyelitis
Acute Hematogeneus OsteomyelitisOperative indications
No improvement with conservative treatmentDrainage of an abscessDebridement of soft tissuesObtaining cultures
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Osteomyelitis
Acute OsteomyelitisAfter open fracture, enfected wounds or ORIFClinical findings are similar to acute hem. OM. S.aureusS. EpidermidisP.AeruginosaColiforms
TreatmentOperation: Radical irrigation+debridement+removal of ortopaedic
hardwareVancomycin+ciprofloxacin/3.generation cephalosporine
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Osteomyelitis
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Osteomyelitis
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Osteomyelitis
Chronic Osteomyelitis Inappropriately treated acute OM, trauma, soft tissue spreadAltered immunity (DM)Skin and soft tissues are mostly involved
Sinus tract: squamous cell carcinomaAcute exacerbations followed by periods of quiescenceDeep tissue cultures obtained in operationMultiple bacterial involvement can be seen
S.aureus, enterobacteriaceae, p.aeruginosa mostly seen Treatment
Operation: Radical irrigation+debridement+removal of ortopaedic hardware+soft tissue covers
Vancomycin+ciprofloxacin/3.generation cephalosporineAmputation
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Osteomyelitis
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Osteomyelitis
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Osteomyelitis
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Osteomyelitis
Subacute OsteomyelitisUsually discovered radiologically in a patient with a
painfull limp and no systemic sign and symptomMay arise from inappropriately treated acute OM, or in a
fracture hematomaBrodie’s abscess
A localised radiolucency in the metaphyses of long bonesDifferential diagnosis with Ewing’s sarcomaS. Aureus is the main causeTreatment
Surgical drainage+curettage+iv Antibiotics(48 hours)+ oral Antibiotics ( 6 weeks)
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Osteomyelitis
Subacute OsteomyelitisBrodie’s abscess
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Osteomyelitis
Chronic Sclerosing Osteomyelitis (Garre)Primarily involves diaphysis Usually seen in adolescentsTypified by intense proliferation of periosteum leading to bony depositionAnaerobic microorganismsLocalized pain and tenderness with dense progressive sclerosis are commonMalignancy must be ruled out
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Septic Arthritis
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Septic Arthritis
Commonly follows hematogeneus spread to synovial membrane or extansion of metaphyseal OM in children
Can happen in direct innoculation (esp. İatrogenic)
In the US and Europe there are approx 20000 cases a year
Commoner in children, the elders and the immune-compromised
Morbidity and mortality depends on organism, with N gonorrhoeae being very low while
S. aureus is high
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Septic Arthritis
Most cases involve infants (HIP) and children40% are aged 65 years and overThe most common scenerio is septic arthritis
follows acute OM of proximal femur in the hipExamination consist aspiration of the pus, US
shows effusion, MRI is useful for soft tissue edema, plain xrays only shows effusion
Surgical drainage and debridement still gold standartArtroscopic debridementDaily aspirationOpen arthrotomy
Parental antibiotics must be used after operation
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Septic Arthritis
With healing can beComplete resolution and a return to normalPartial loss os cartilage and fibrosis of the jointLoss of cartilage and bony ankylosisBone destruction and permanent deformity of the
joint
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Septic Arthritis
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Septic Arthritis
Newborn (<4 months)ChildrenAcute Monoartricular Septic Arthritis in
Sexually Active AdultsAcute Monoartricular Septic Arthritis in not
Sexually Active AdultsChronic Monoartricular Septic ArthritisPolyartricular Septic Arthritis
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Septic Arthritis
Newborn (<4 months)Especially seen in hipNewborn with sore hip and tenderness and
irritable and sometimes fever is the thypical scenerio
S. Aureus, Gr. B Strep., EnterobacteriaceaeAdjacent bony involvement seen in %70Blood cultures mostly positivePRSP + 3. generation cephalosporin
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Septic Arthritis
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Septic Arthritis
ChildrenEspecially seen in knee and hip (pseudoparalysis)S. Aureus, H. Influenzae.,Str. Pyogenes, Str.
PneumoniaePRSP+3. generation cephalosporin
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Bone and Joint Infections
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Septic Arthritis
Acute Monoartricular Septic Arthritis in Sexually Active AdultsEspecially seen in knee, wrist and ankleN. Gonorrhoaeae, S. Aureus, StreptococciCeftriaxone/cefotaxime/ceftizoxime +/-oxacillin
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Septic Arthritis
Acute Monoartricular Septic Arthritis in not Sexually Active Adults Especially seen in kneeS. Aureus, Streptococci, Gr- BacilliPRSP+3. generation cephalosporin
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Septic Arthritis
Chronic Monoartricular Septic ArthritisBrucellaMycobacteria tuberculosisNocardiaFungi
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Septic Arthritis
Polyartricular Septic ArthritisGonococciBorrelia BurdogferiViruses
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Specific Infections
TuberculosisCommonly seen in large joints and spineCauses granulomatous reaction which is associated with
necrosis and caseation%5 Tbc patients have bone and joint involvementİliopsoas abycess and pott diseaseMostly heals with fibrous ankylosis
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Bone and Joint Infections
BrucellosisSubacute or chronic granulomatous infectionB.Melitensis, B. Abortus, B. SuisChronic inflammatory granuloma with giant cells is
characteristic and seen mostly in vertebral bodies and synovium of large joints
Undulant Fever, headache, generalizes weakness and generalized joint pain and backache
Positive agglutination testTetracycline+streptomycin for 4 weeks
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Thank you …