OsteomyelitisSeptic Arthritis

Melih Güven, M.DAssoc. Prof.

Yeditepe University HospitalDepartment of Orthopaedics and Traumatology

Istanbul

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

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

Osteomyelitis

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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

Osteomyelitis

Acute Hematogeneus OsteomyelitisNewbornChildren AdultsSickle Cell AnemiaHemodialysis and iv Drug abused patients

Acute osteomyelitisChronic OsteomyelitisSubacute OsteomyelitisChronic Sclerosing Osteomyelitis

Osteomyelitis

Microorganisms enter bone (Phagocytosis)

Phagocyte contains the infection

Release enzymes

Lyse bone

Osteomyelitis

Bacteria escape host defenses by:

Adhering tightly to damage bone

Persisting in osteoblasts

Protective polysaccharide-rich biofilm

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)

Osteomyelitis

Osteomyelitis

Acute Infiltration of PMNs Congested or thrombosed vessels

Chronic Necrotic bone Absence of living osteocyte Mononuclear cells predominate Granulation & fibrous tissue

Osteomyelitis

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

Osteomyelitis

Acute Hematogeneus OsteomyelitisNewborn(<4 months of age)

S. AureusGr- bacilliGroup B str.Treatment

Treat like sepsisOxacilin+3. generation cephalosporin

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

Osteomyelitis

Acute Hematogeneus OsteomyelitisAdults

S. AureusTreatment

Nafcilin/oxacilin/cefazolin/vancomycin

Osteomyelitis

Acute Hematogeneus OsteomyelitisSickle Cell Anemia

SalmonellaTreatment

Flouroquinolones/3. generation cephalosporine

Osteomyelitis

Acute Hematogeneus OsteomyelitisHemodialysis and iv Drug abused patients

S.aureusS. EpidermidisP.AeruginosaTreatment

Vancomycin+ciprofloxacin

Osteomyelitis

Acute Hematogeneus OsteomyelitisOperative indications

No improvement with conservative treatmentDrainage of an abscessDebridement of soft tissuesObtaining cultures

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

Osteomyelitis

Osteomyelitis

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

Osteomyelitis

Osteomyelitis

Osteomyelitis

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)

Osteomyelitis

Subacute OsteomyelitisBrodie’s abscess

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

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

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

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

Septic Arthritis

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

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

Septic Arthritis

Septic Arthritis

ChildrenEspecially seen in knee and hip (pseudoparalysis)S. Aureus, H. Influenzae.,Str. Pyogenes, Str.

PneumoniaePRSP+3. generation cephalosporin

Bone and Joint Infections

Septic Arthritis

Acute Monoartricular Septic Arthritis in Sexually Active AdultsEspecially seen in knee, wrist and ankleN. Gonorrhoaeae, S. Aureus, StreptococciCeftriaxone/cefotaxime/ceftizoxime +/-oxacillin

Septic Arthritis

Acute Monoartricular Septic Arthritis in not Sexually Active Adults Especially seen in kneeS. Aureus, Streptococci, Gr- BacilliPRSP+3. generation cephalosporin

Septic Arthritis

Chronic Monoartricular Septic ArthritisBrucellaMycobacteria tuberculosisNocardiaFungi

Septic Arthritis

Polyartricular Septic ArthritisGonococciBorrelia BurdogferiViruses

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

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

Thank you …